Longitudinal assessment of coping abilities at exacerbation and stabilization in schizophrenia

Relations between changes in safety behavior, paranoid ideations, cognitive biases, and clinical characteristics of patients with a psychotic disorder over time

BACKGROUND

Safety behaviors, both positive (maladaptive coping behavior) and negative (avoidance behavior), are used by people with paranoid delusions to avoid perceived threats. Safety behaviors contribute to the persistence of paranoid delusions by preventing disconfirmation of threat beliefs and may influence other psychiatric symptoms. This study investigated how changes in safety behaviors are related to changes in paranoid ideation, social anxiety, depression, cognitive biases and self-esteem over time.

METHODS

This study included 116 patients diagnosed with a psychotic disorder (DSM-IV) and at least moderate levels of paranoid ideations (GTPS >40).The data were collected as part of a multi-center randomized controlled trial where patients were randomized to VR-CBT (n = 58) or treatment as usual (TAU; n = 58). Assessments were completed at baseline (T0), after three months (T3) and after six months (T6). For all variables, change scores between T0 and T3 and T3 and T6 were calculated and Pearson correlations between change scores were computed.

RESULTS

A decrease in total safety behavior was related to diminished paranoid ideation, social anxiety, and depression. No significant temporal associations were found between changes in safety behavior and changes in cognitive biases and self-esteem. Similar but less robust results were found for respectively negative safety behavior and positive safety behavior.

CONCLUSION

Dropping safety behavior can be specifically targeted in behavioral interventions. Whereas there appears to be a relation with reduction in anxiety, paranoia, and depressive symptoms, changes in safety behavior do not seem to align with changes in cognitive thinking processes.

Training coping skills and coping with stress self-efficacy for successful daily functioning and improved clinical status in patients with psychosis: A randomized controlled pilot study

Due to the symptom diversity and pervasive function impairments (e.g. in perception, cognition, language, affect, behavior, daily and social functioning and sense of self), recurrent relapses, elevated disability, high rates of (co)morbidity, heightened premature mortality and high burden of care of psychotic disorders, psychosocial interventions are part of patients' standard care. There is growing evidence on the relevance of self-efficacy for well-being and functioning among these patients, but specific coping with stress self-efficacy has rarely been investigated. This study explored the outcomes of an intervention for the improvement of coping resources based on training in coping skills and coping with stress self-efficacy. Fourteen adult volunteers with schizophrenia (n = 12) or schizoaffective disorder (n = 2) were matched in clinical and sociodemographic characteristics and randomly assigned to the study groups. The intervention group received the training-with 15 twice per week sessions (8 weeks)-along with their pharmacological therapy; the control group received their prescribed drug therapy. Participants completed self-reports on coping with stress self-efficacy, perceived successful daily functioning based on coping skills and clinical status (Expanded Brief Psychiatric Rating Scale). Trained patients showed a significant increase in coping with stress self-efficacy and reported greater successful functioning status, and significant improvements in their clinical status were also observed. All these enhancements remained at 3-month and 6-month follow-ups. The intervention condition interacted with coping with stress self-efficacy and perceived coping functioning in explaining improvements in clinical status: in the treatment group, greater coping with stress self-efficacy translated into enhanced daily functioning, and this improvement predicted better clinical status. These findings stress the relevance of promoting coping resources in psychotic disorders and provide preliminary evidence for the potential benefits of coping with stress self-efficacy.

Role of Religion in Psychotic Illness in the Israeli Ultra-Orthodox Jewish Population: Patient Beliefs and Expectations

ABSTRACT

This study aims to describe the role that religion and belief may play in members of the Israeli ultra-Orthodox Jewish population hospitalized in the Mayanei Hayeshua Medical Center and diagnosed with a psychotic disorder. Religion was judged essential by the patients in the management of their illness. Forty percent of the patients perceive their illness as their destiny, 26.7% as an "affliction of love," and 33.3% as resulting from their sins. Sixty percent of patients explained that faith is a source of hope in their life, with 76.7% indicating that collective religious practices help them face their illness. Ninety percent expressed no conflict between consulting a psychiatrist and their religious beliefs. Collective religious practices were correlated with higher treatment credibility. The use of religious coping methods was correlated with lower anxiety and tension among women. Higher conflict between religion and consulting a psychiatrist was correlated with lower treatment credibility among men.

Quality of life in individuals with attenuated psychotic symptoms: Possible role of anxiety, depressive symptoms, and socio-cognitive impairments

Individuals with Clinical High-Risk state for Psychosis (CHR-P) are reported to exhibit impaired quality of life (QOL) similar to that observed in schizophrenia, but its determinants remain unclear. We investigated the QOL of 33 subjects with CHR-P, 45 patients with schizophrenia, and 63 healthy subjects using the Quality of Life Scale (QLS). The CHR-P and schizophrenia groups were administered the Brief Assessment of Cognition in Schizophrenia (BACS), the Schizophrenia Cognition Rating Scale (SCoRS), and the Social and Occupational Functioning Assessment Scale (SOFAS) for socio-cognitive functions; and the Positive and Negative Syndrome Scale (PANSS) and the State-Trait Anxiety Inventory for clinical symptoms. The CHR-P group was also assessed using the Beck Depression Inventory. The CHR-P and schizophrenia groups had a significantly lower QLS score to the same degree compared with controls, which was predominantly associated with the SOFAS, SCoRS, and PANSS negative/general scores. For the CHR-P, the severity of anxiety and depressive symptoms was also correlated with a lower QLS score. Regression analyses demonstrated that the QLS score was predicted by SOFAS (for both groups) and SCoRS (for CHR-P) scores. Our findings suggest the importance of addressing socio-cognitive dysfunctions as well as anxiety and depressive symptoms for better QOL in CHR-P.

An exploration of the relationship between use of safety-seeking behaviours and psychosis: A systematic review and meta-analysis

Safety-seeking behaviours are responses employed to protect against perceived threat. In relation to anxiety disorders, safety-seeking behaviours have been implicated in both the formation and maintenance of distress. Several studies have highlighted similar findings in relation to psychosis; however, this literature has not yet been synthesized. This review is, therefore, being conducted in order to synthesize the literature on safety seeking in people with psychosis to increase the understanding of this relationship. A systematic search identified and included 43 studies comprising 2,592 participants, published between 1995 and 2015. The results indicated that people experiencing psychosis commonly respond to their experiences with behavioural and cognitive strategies intended to manage their difficulties. In relation to safety seeking, avoidance, and resistance, there was a pattern that these responses are associated with increased distress and appraisals of threat. The results relating to engagement response styles showed the opposite pattern. These results provide support for cognitive models of safety seeking and psychosis with many of the meta-analyses reported here showing a clear pattern of association between behavioural responses and distress. However, the results reported within individual studies are mixed. This appears to be particularly true with the response style of distraction, with our analyses unable to clarify this relationship. It is possible that the mixed results could reflect the complexities in defining safety seeking and distinguishing it from coping in this population. The clinical implications of this are discussed.

Coping strategies in schizoaffective disorder and schizophrenia: Differences and similarities

Aims of the current study were to explore differences in coping between 58 patients with schizoaffective disorder (SAD) and 89 with schizophrenia (SZ) and to identify factors associated with coping in both disorders. The demographic and clinical characteristics of patients with SAD and with SZ were compared using ANOVA and χ(2). Pearson's correlations were calculated between coping styles and socio-demographic and clinical variables in each group. The significant ones were subsequently analyzed using multiple regressions. Patients with SAD used emotion oriented coping more frequently than patients 2016with SZ. In patients with SAD, self-esteem contributed to task-oriented; avolition-anhedonia (AA) to emotion-oriented; duration of illness and years of education to distraction; AA to social diversion. In patients with SZ, AA, the mental component summary score of the Short Form - 36 Health Survey (SF-36) and self-esteem contributed to emotion oriented coping; the mental component summary score of SF-36 to distraction; AA to social diversion. Our results suggest that patients with SAD and SZ use diverse coping strategies. A greater attention must be given to the presence of self-esteem and AA in individuals with both disorders. These factors are potentially modifiable from specific therapeutic interventions, which can produce effects on coping strategies.

Coping strategies and self-stigma in patients with schizophrenia-spectrum disorders

BACKGROUND

Maladaptive coping strategies may adversely disturb the overall functioning of people with mental disorders. Also, self-stigma is considered a maladaptive psychosocial phenomenon that can affect many areas of patient life. It has a negative impact on self-image, and may lead to dysphoria, social isolation, reduced adherence, using of negative coping strategies, and lower quality of life. The objective of this study was to determine the relationship between coping strategies and self-stigma among persons with schizophrenia and related psychotic disorders.

SUBJECTS AND METHODS

A total of 104 clinically stable outpatients with chronic schizophrenia-spectrum disorders were enrolled in a cross-sectional study. Sociodemographic and clinical data were recorded. Patients were examined by psychiatrists with the Stress Coping Style Questionnaire, the Internalized Stigma of Mental Illness scale, and the Clinical Global Impression scale. Correlation and multiple-regression analyses were performed to discover contributing factors to self-stigma.

RESULTS

Positive coping strategies were used by patients with schizophrenia-spectrum disorders to the same extent as in the healthy population. Negative coping strategies were overused by these patients. There were significant associations between self-stigma, severity of the disorder, and coping strategies in schizophrenia. The ability to use positive coping strategies was connected with lower self-stigma. Use of negative coping strategies predominantly increased the self-stigma of patients with schizophrenia.

CONCLUSION

This study revealed a significant association among self-stigma, severity of the disorder, and coping strategies in individuals suffering from schizophrenia-spectrum disorders. Thinking about coping strategies and self-stigma in practice may play a significant role in understanding people with schizophrenia-spectrum disorders, especially for mental health professionals.

The impact of neuropsychological functioning and coping style on perceived stress in individuals with first-episode psychosis and healthy controls

Stress is implicated in the development and course of psychotic illness, but the factors that influence stress levels are not well understood. The aim of this study was to examine the impact of neuropsychological functioning and coping styles on perceived stress in people with first-episode psychosis (FEP) and healthy controls (HC). Thirty-four minimally treated FEP patients from the Early Psychosis Prevention and Intervention Centre, Melbourne, Australia, and 26 HC participants from a similar demographic area participated in the study. Participants completed a comprehensive neuropsychological test battery as well as the Coping Inventory for Stressful Situations (task-, emotion- and avoidance-focussed coping styles) and Perceived Stress Scale (PSS). Linear regressions were used to determine the contribution of neuropsychological functioning and coping style to perceived stress in the two groups. In the FEP group, higher levels of emotion-focussed and lower levels of task-focussed coping were associated with elevated stress. Higher premorbid IQ and working memory were also associated with higher subjective stress. In the HC group, higher levels of emotion-focussed coping, and contrary to the FEP group, lower premorbid IQ, working memory and executive functioning, were associated with increased stress. Lower intellectual functioning may provide some protection against perceived stress in FEP.

Relative contributions of negative symptoms, insight, and coping strategies to quality of life in stable schizophrenia

The purpose of this cross-sectional study was to examine the relative contributions of negative symptomatology, insight, and coping to quality of life (QOL) in a sample of 92 consecutive outpatients with stable schizophrenia referring to the Department of Neuroscience, Psychiatric Section, University of Turin, Struttura Semplice di Coordinamento a Valenza Dipartimentale (SSCVD), Department of Mental Health ASL TO1, Molinette, Italy, in the period between July 2009 and July 2011. In order to assess the specific effect of negative symptoms on QOL and the possible mediating role of insight and coping, two mediation hypotheses were tested, using multiple regression analyses specified by Baron and Kenny (1986). Our findings suggest that (a) higher negative symptoms predict a worse Quality of Life Scale (QLS) intrapsychic foundations (IF) subscale score; (b) attribution of symptoms and coping-social diversion have a direct and positive association with QLS-IF; (c) patients high in negative symptoms are less likely to use attribution of symptoms and coping-social diversion; and (d) attribution of symptoms and coping-social diversion act as partial mediators in the negative symptoms-QOL relationship. The prediction model accounts for 45.3% of the variance of the QLS-IF subscale score in our sample. In conclusion, our results suggest that insight and coping-social diversion substantially contribute to QOL in patients with higher negative symptoms. These factors are potentially modifiable from specific therapeutic interventions, which can produce considerable improvements in the QOL of this population.

Differences in coping, self-efficacy, and external control beliefs between patients at-risk for psychosis and patients with first-episode psychosis

Patients with first-episode psychosis (FEP) often show dysfunctional coping patterns, low self-efficacy, and external control beliefs that are considered to be risk factors for the development of psychosis. Therefore, these factors should already be present in patients at-risk for psychosis (AR). We compared frequencies of deficits in coping strategies (Stress-Coping-Questionnaires, SVF-120/SVF-KJ), self-efficacy, and control beliefs (Competence and Control Beliefs Questionnaire, FKK) between AR (n=21) and FEP (n=22) patients using a cross-sectional design. Correlations among coping, self-efficacy, and control beliefs were assessed in both groups. The majority of AR and FEP patients demonstrated deficits in coping skills, self-efficacy, and control beliefs. However, AR patients more frequently reported a lack of positive coping strategies, low self-efficacy, and a fatalistic externalizing bias. In contrast, FEP patients were characterized by being overly self-confident. These findings suggest that dysfunctional coping, self-efficacy, and control beliefs are already evident in AR patients, though different from those in FEP patients. The pattern of deficits in AR patients closely resembles that of depressive patients, which may reflect high levels of depressiveness in AR patients. Apart from being worthwhile treatment targets, these coping and belief patterns are promising candidates for predicting outcome in AR patients, including the conversion to psychosis.

Eye of the beholder: perceived stress, coping style, and coping effectiveness among discharged psychiatric patients

Sources of perceived stress, coping style and coping efficacy were investigated among psychiatric patients being discharged to the community. The study's purpose was to (i) qualitatively characterize sources of perceived stress; (ii) identify preferred coping styles, and (iii) test the effectiveness of coping styles. Thematic coding of participants' narratives revealed that dominant stressors were family relationships, mental health symptoms, and employment issues. Consistent with previous findings among non-clinical samples, problem-focused coping styles were predictive of decreased perceived stress and increased perceived efficacy, whereas emotion-oriented coping styles were negatively associated with these outcomes. Contrary to hypotheses, avoidance coping styles was unrelated to outcomes.

Factor structure in the Camberwell Assessment of Need-Patient Version: the correlations with dimensions of illness, personality and quality of life of schizophrenia patients

AIM

To investigate the factor structure underlying the Camberwell Assessment of Need-Patient Version (CANSAS-P) items in schizophrenia and schizoaffective disorder.

METHOD

Factor, correlation and regression analyses were performed for dimensions of CANSAS-P, illness, personality and quality of life (QOL) related variables in 95 stabilized patients with chronic schizophrenia and schizoaffective disorder.

RESULTS

Exploratory factor analysis revealed a four-factor model that explains 50.4% of the total variance of the 20 CANSAS-P items. The factors 'Social disability', 'Information processing disability', 'Emotional processing disability', and 'Coping disability' showed acceptable internal consistency (Cronbach's α coefficient 0.67-0.77). The CANSAS-P subscale scores positively correlated with severity of symptoms, distress (r ranged from 0.34 to 0.45), while negatively associated with general functioning (r = -0.34), friend (r = -0.46) and family support (r = -0.41), satisfaction with medicine (r = -0.35), general activities (r = -0.40), and general QOL (r = -0.35) (all P < 0.001). Severity of illness, symptoms, emotional distress and emotion-oriented coping were positive predictors; friend support, QOL general activities, life satisfaction and satisfaction with medicine were negative predictors of the CANSAS-P subscale scores. The effect size (f(2)) for these predictors ranged from medium to quite large (f(2) = 0.28-1.13), and they explain from 23% to 46% of the variability in CANSAS-P subscales.

CONCLUSIONS

A four-factor structure mode, including social and cognitive functioning, emotion responsivity and coping with daily challenges, appears to fit CANSAS-P items. These subscales may contribute to research and improve treatment of psychiatric patients.

The relationship between coping and subclinical psychotic experiences in adolescents from the general population--a longitudinal study

BACKGROUND

Subclinical psychotic experiences during adolescence may represent liability for developing psychotic disorder. Both coping style and the degree of persistence of psychotic experiences may play a role in the progression to clinical psychotic disorder, but little is known about the causal relationship between the two.

METHOD

Path modelling was used to examine longitudinal relationships between subclinical positive psychotic experiences and three styles of coping (task-, emotion- and avoidance-oriented) in an adolescent general population sample (n=813) assessed three times in 3 years. Distinct developmental trajectories of psychotic experiences, identified with growth mixture modelling, were compared on the use of these coping styles.

RESULTS

Over time, emotion-oriented coping in general was bi-directionally related to psychotic experiences. No meaningful results were found for task- or avoidance-oriented coping. Females reported using a wider range of coping styles than males, but the paths between coping and psychotic experiences did not differ by gender. Persistence of psychotic experiences was associated with a greater use of emotion-oriented coping, whereas a decrease in experiences over time was associated with an increased use of task-orientated coping.

CONCLUSIONS

Emotion-oriented coping is the most important coping style in relation to psychotic experiences, as it may contribute to a 'vicious cycle' and is associated with persistence of experiences. In addition, more task-oriented coping may result in a decrease in psychotic experiences. Results suggest that opportunities for intervention may already be present at the level of subclinical psychosis.

Ways of coping in adolescents with schizophrenia

The purpose of this study was to explore ways of coping and its association with specific stress responses in adolescents with schizophrenia. Additionally, subjects and healthy controls were compared to identify stress responses. Forty subjects were drawn from a self-management therapy study for youth with schizophrenia. Thirty community-dwelling controls were selected. A revised Ways of Coping scale and the Symptom of Stress at baseline, 6, 30 and 54 weeks measured coping and stress response. Descriptive statistics, cluster analysis and Pearson correlation provided data analysis. Thirty-two subjects were male, and eight were female. Average age was 17.25 (SD=1.37) years. Twenty-two (55%) were Caucasian; 18 (45%) were non-Caucasian. Seventeen (57%) of the 30 controls were female. The mean age was 17.10 years old (SD=1.16). Adolescents with schizophrenia used emotion-focused coping more than problem-focused coping at baseline and 6 weeks (P<0.01). Subjects reported higher stress than controls (t=4.73, P<0.01) and used emotion-focused coping with emotional stress responses (r=0.34, P=0.05). Adolescent coping strategies may persist into adulthood unless new skills are introduced. Developing effective coping skills for adolescents with schizophrenia is important for practice and future studies.

Coping strategies and their relationship to psychopathologies in people at ultra high-risk for psychosis and with schizophrenia

This study's aim was to investigate coping strategies and their relationship to symptoms in people at ultra high risk (UHR) for psychosis compared with recent-onset schizophrenia (SPR) and healthy controls. Thirty-three UHR participants, 22 SPR patients, and 33 healthy controls completed the Ways of Coping Questionnaire and other clinical measures. People at UHR for psychosis showed significantly more reliance on tension-reduction and less reliance on problem-focused coping than healthy controls. The SPR group showed more reliance on tension-reduction coping than healthy controls at a trend level. Maladaptive coping patterns were associated with higher levels of negative symptoms, depression, and anxiety in both the UHR and SPR groups. These findings suggest that maladaptive coping strategies might have already emerged in the (putative) prodromal stage and could influence symptom severities.

The Impact of Illness Identity on Recovery from Severe Mental Illness

The impact of the experience and diagnosis of mental illness on one's identity has long been recognized; however, little is known about the impact of illness identity, which we define as the set of roles and attitudes that a person has developed in relation to his or her understanding of having a mental illness. The present article proposes a theoretically driven model of the impact of illness identity on the course and recovery from severe mental illness and reviews relevant research. We propose that accepting a definition of oneself as mentally ill and assuming that mental illness means incompetence and inadequacy impact hope and self-esteem, which further impact suicide risk, coping, social interaction, vocational functioning, and symptom severity. Evidence supports most of the predictions made by the model. Implications for psychiatric rehabilitation services are discussed.

Are symptoms associated with increased levels of perceived stress in first-episode psychosis?

Several studies report on the presence of external stress and life events prior to the onset and exacerbation of psychotic illness. However, the relationship between the subjective appraisal of stress at first presentation with psychosis is less well understood. This paper reports on the relationship between the individual perception of stress and symptomatology in individuals with first-episode psychosis at presentation to community mental health services. We assessed 123 individuals using standardized measures of symptoms, quality of life, perceived stress, global functioning, and duration of untreated psychosis. At first presentation, people with more depressive symptoms and reduced overall functioning were more likely to report increased levels of perceived stress. In addition, people with less positive symptoms of psychosis were experiencing higher levels of subjective stress. In terms of stress vulnerability models, it is important to consider how functioning and symptoms can influence individual appraisal of stress. Acknowledging this interaction can provide opportunities for nursing interventions directed at enhancing adaptive coping and provide benchmarks for assessing the effectiveness of nursing interventions provided in the acute phase of psychosis. Further research should focus on the interaction between symptoms and individually-appraised stress over time.

Coping patterns as a valid presentation of the diversity of coping responses in schizophrenia patients

This study aimed to identify coping patterns used by schizophrenia inpatients in comparison with those used by healthy individuals, and to explore their association with selected clinical and psychosocial variables. The Coping Inventory for Stressful Situations (CISS) was used to assess coping strategies among 237 inpatients who met DSM-IV criteria for schizophrenia and 175 healthy individuals. Severity of psychopathology and distress, insight into illness, feelings of self-efficacy and self-esteem (self-construct variables), social support, and quality of life were also examined. Factor analysis, analysis of covariance and correlations were used to examine the relationships between the parameters of interest. Using dimensional measures, we found that emotion-oriented coping style and emotional distress were significantly higher in the schizophrenia group, whereas the task-oriented coping style, self-efficacy, perceived social support and satisfaction with quality of life were lower compared with controls. When eight CISS coping patterns were defined, the results revealed that patients used emotion coping patterns 5.5 times more frequently, and task and task-avoidance coping patterns significantly less often than healthy subjects. Coping patterns have different associations with current levels of dysphoric mood and emotional distress, self-construct variables, and satisfaction with quality of life. Thus, the identified coping patterns may be an additional useful presentation of the diversity of coping strategies used by schizophrenia patients. Coping patterns may be considered an important source of knowledge for patients who struggle with the illness and for mental health professionals who work with schizophrenia patients.

The long-term changes in coping strategies in schizophrenia: temporal coping types

This prospective study aimed to define the long-term changes in coping strategies used by schizophrenia patients and their relation to clinical and psychosocial factors. The Coping Inventory for Stressful Situations, psychiatric scales, and self-report questionnaires were administered to 148 schizophrenia patients at admission and 16 months thereafter. Based on trends of individual coping patterns to show change over time, four temporal coping types were distinguished: stable favorable and unfavorable, and becoming favorable and unfavorable. We found that coping patterns of 62.2% of patients remained stable over time, became unfavorable among 19.6% of patients, and became favorable among 18.2% of patients. Each temporal coping type is associated with a specific pattern of changes in clinical and psychosocial variables. The findings underscore the clinical relevance of temporal coping types and corroborate the appropriateness of focusing on aspects of coping behavior in treatment and rehabilitation of schizophrenia patients.