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The stress-vulnerability model of schizophrenia proposes that psychosocial stressors are a pervasive risk factor contributing to the onset of psychosis.[1, 2] According to this model, poor coping responses to these stressors are fundamental to the development, course and outcome of illness. Coping refers to the cognitive processes and behaviours in which one engages to tolerate or minimize stress. In patients with schizophrenia, coping style is significantly correlated with both severity of clinical symptomatology and psychosocial functioning, and indeed mediates the relationship between them. In addition, coping styles in schizophrenia patients are related to quality of life,[5, 6] distress about one's illness, cognitive abilities, social functioning and negative mood changes during a laboratory psychosocial stress task. In schizophrenia patients with a recent onset of illness, coping styles affect levels of self-efficacy, cognitive performance, psychosocial functioning, clinical symptomatology and quality of life. Collectively, these findings suggest that coping styles affect multiple domains of functioning and quality of life in individuals with a psychotic disorder, including those whose symptoms have appeared only recently.
In an attempt to reduce the chronic and severe disability associated with schizophrenia, there have been increasing efforts to identify and provide interventions for individuals who are at clinical high risk (CHR) for developing the disorder.[13-15] Primary goals in early intervention research are to prevent deterioration in functioning, decrease severity of symptoms over time and lower the amount of stress that individuals experience. Given the clear relevance of coping styles to symptoms and functioning in schizophrenia patients, examining coping styles in CHR individuals – and their relationship to changes in clinical symptomatology and psychosocial outcome – may ultimately contribute to the development of more effective intervention strategies.
Two studies investigating coping style in CHR individuals were recently published. The first showed that, in comparison with controls, CHR individuals report engaging in active coping less often. Additionally, Lee and colleagues found that maladaptive coping was significantly related to negative symptoms in CHR individuals. However, both studies were cross-sectional in design and thus cannot address how coping may change over time, nor how coping styles may relate to changes in clinical symptomatology. Employing a longitudinal design, a recent study in an adolescent general population sample found that adaptive coping styles were related to a decrease in self-reported subclinical positive psychotic experiences over time, whereas maladaptive coping styles were related to an increase in such experiences. However, these were not help-seeking individuals, and psychotic experiences were measured via a self-report questionnaire. Associations between symptoms and coping styles over time have yet to be examined in help-seeking individuals meeting criteria for a putative prodromal syndrome.
It is important to note that, unlike patients with established illness, those at risk for schizophrenia are typically adolescents, undergoing developmental changes that are accompanied by a host of distinct stressors. Notably, poor coping strategies have been linked to lower levels of psychosocial health and increased behavioural problems in typically developing adolescents.[20, 21] At the same time, healthy adolescents tend to develop a wider repertoire of coping strategies and become more active in their coping styles as they get older (e.g. showing an increased use of strategies such as problem solving or seeking emotional support[22, 23]). Thus, examining the developmental trajectory of coping styles in CHR individuals may also be important for understanding developmental effects on stress response.
The Brief COPE questionnaire, a short, well-validated measure that assesses how individuals respond to stressful events, has been successfully used to examine coping patterns in schizophrenia patients. Here we used the Brief COPE to identify the types of coping styles employed by CHR youth and to assess whether these coping strategies are different from their same-age peers. Based on prior findings in patients with schizophrenia,[4, 10] we first hypothesized that, in comparison with healthy participants, CHR individuals would implement fewer adaptive coping techniques and use more maladaptive coping strategies. Second, to better characterize how coping strategies are related to other clinical characteristics in CHR individuals, we examined the association between baseline coping styles and current symptomatology. In accordance with previous findings, we hypothesized that lower levels of adaptive coping would be associated with more severe clinical symptomatology. Finally, we explored whether coping styles in CHR individuals changed over a 1-year follow-up period, and how coping style was associated with clinical symptomatology and psychosocial functioning over that time frame. Specifically, we investigated whether: (i) baseline coping profiles were predictive of symptom trajectories; and (ii) coping strategies were associated with concurrent symptoms over time.
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This study revealed several novel findings regarding the relationships between coping style, clinical symptomatology and psychosocial outcome in youth at clinical high risk for psychosis. Cross-sectional analyses revealed that relative to healthy controls, CHR youth reported using significantly fewer adaptive coping strategies and more maladaptive coping strategies (Fig. 1). In addition, there were effects of both IQ and development; in particular, higher IQ was associated with higher levels of adaptive coping in controls, but not in CHR patients. In contrast, increasing age was associated with higher levels of adaptive coping in both CHR patients and controls, indicating that both groups are more likely to implement adaptive coping strategies as they grow older.
Figure 1. Baseline coping styles of clinical high risk (CHR) individuals versus healthy controls. *P < 0.01, **P < 0.001. () Controls (n = 53), () CHR individuals (n = 88).
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In our longitudinal analyses of CHR individuals, adaptive coping did not significantly change over the 12-month period, but there were significant decreases in reported maladaptive coping strategies, along with significant improvements in psychosocial functioning and decreases in clinical symptomatology. Over time, adaptive coping was associated with better social functioning and less severe negative and disorganized symptoms. Additionally, over the 12-month period, more maladaptive coping strategies were associated with more severe clinical symptomatology. Finally, our time-varying covariate analysis of coping styles indicated that overall better coping strategies were associated with better concurrent outcomes.
These results are consistent with findings from previous studies that examined coping styles of patients with established schizophrenia diagnoses.[4, 10] In addition, our findings extend into the critical period prior to the onset of full psychosis. In comparison with same-age, healthy participants, CHR individuals are less likely to engage in adaptive coping strategies, and more likely to engage in maladaptive behaviours. These results suggest that, like those with a diagnosis of schizophrenia, CHR youth may not possess the skills to effectively cope with stressful situations. Additionally, when CHR individuals do attempt to cope with stressful situations, they may use strategies that may be detrimental to their functioning or exacerbate symptomatology.
These findings are also consistent with and build upon two recent cross-sectional studies. Pruessner and colleagues found that CHR individuals showed reduced levels of active coping, a specific type of adaptive coping measured by the Brief COPE, which we also found to be reduced in CHR individuals. Furthermore, similar to our findings, Lee and colleagues showed that maladaptive coping was significantly related to negative symptoms in CHR individuals. However, both of these studies included smaller sample sizes and did not include a longitudinal component, two strengths of the current study. Additionally, in a recent population-based study of adolescents, Lin and colleagues found that increased use of emotion-oriented coping styles (described as self-oriented emotional reactions, self-preoccupation and fantasizing) was associated with an increase in subclinical psychotic experiences, which is consistent with our finding of a significant relationship between maladaptive coping and positive symptoms over time in CHR individuals. The present study, however, establishes this relationship in a help-seeking population.
When observing relationships between baseline coping style and concurrent outcome variables, two significant findings emerged. Individuals who reported engaging in more adaptive coping styles had fewer negative symptoms and higher levels of social functioning. However, we did not identify a relationship between positive symptoms and coping styles, which Meyer observed in patients with chronic schizophrenia. This difference may be due to the fact that our study participants are not experiencing full-blown positive psychotic symptoms, with the present findings suggesting that the association between coping style and negative symptoms and social functioning emerges prior to the association between coping and positive symptoms. In support of our findings, two previous studies examining individuals at CHR who do not convert to psychosis, including some individuals with attenuated positive symptoms which remitted entirely over the course of follow-up, continued to display impaired social functioning.[33, 34] Thus, the association between coping style and negative symptoms and social functioning may therefore prove a valuable early target for relatively early-stage clinical intervention, as discussed next.
Certain limitations of this study must be noted. First, it would have been optimal to observe longitudinal changes in a healthy control sample, to determine whether the changes seen in CHR individuals' coping styles in a 12-month period are developmentally appropriate. However, due to low rates of completion of the coping measurement at the 6 (74% attrition) and 12 (90% attrition) month points for healthy controls, this analysis was not possible. Given that there were no significant differences in baseline clinical or demographic variables between CHR individuals who dropped out and those who remained in the study, we do not believe that our results are driven by a selection bias, but this possibility cannot be definitively ruled out. Another limitation of our study is that we did not directly assess the number and type of stressful events in the participants' lives, and how these events may have contributed to how effectively an individual was coping. For example, if a CHR individual is distressed by his/her psychotic symptoms, he/she may cope differently with this stressor than another (e.g. difficulty with academics). Larger samples and a more fine-grained characterization of life stress would be necessary to show such conditional associations. Notably, we did not find that baseline coping style predicted subsequent symptomatic and functional trajectories. It is possible that our study was under-powered to detect significant coping by time interactions. However, the lack of findings may also be due to the fact that coping styles are not static traits with predictive value for symptom levels and functioning in CHR individuals. Instead, our findings suggest that coping styles correspond to one's current functioning level or severity of symptoms, and are likely to represent important factors in a dynamic process of attempting to mediate one's vulnerability to stress. For instance, given that CHR patients' cumulative experience of ‘daily hassles’ correlates with plasma cortisol level, which in turn predicts symptoms of depression and anxiety and may even precipitate psychotic symptoms, it is reasonable to imagine that the experience of stress worsens symptoms, which degrades adaptive coping, in turn increasing stress, and on in a feed-forward cycle – consistent with the results of our time-varying covariate analysis. Intervention designed to slow or stop this cycle by bolstering an individual's adaptive coping resources may in turn slow symptom exacerbation. In fact, similarly conceptualized approaches are in wide use to prevent relapse among remitted schizophrenia patients. Alternatively, the self-reported use of adaptive and maladaptive coping patterns may track with concurrent symptoms because what is measured in an instrument such as the Brief COPE is analogous to what is measured in instruments for symptoms and functioning. Finally, due to the sample size limitations, we did not examine coping in relation to conversion to psychosis in CHR individuals.
These findings have important implications for the development of clinical interventions for CHR individuals. We found that, regardless of medication being prescribed or type of psychosocial treatment one is engaged in, maladaptive coping styles decreased over time. This finding suggests that maladaptive coping styles may be more malleable and easier to target than adaptive coping styles. Additionally, given that we found a strong relationship between adaptive coping and social functioning in CHR individuals, it may be effective to implement social skills training programmes, which teach adaptive coping styles (e.g. problem solving in interpersonal situations) and may lead to improvement in social functioning. Social skills training programmes have shown promising results for both schizophrenia patients and typically developing adolescents.
Future studies are warranted to determine why CHR individuals are less likely to use adaptive coping strategies, but more likely to engage in maladaptive ones. A recently published study on CHR youth showed that perceptions of one's ability to cope with stressful situations, along with the appraisals of stressful life events experienced, influenced the type of coping style that one employed. Furthermore, investigating the relationship between coping styles, appraisal of stressful life events and symptomatology may provide us with a better understanding of the stress-vulnerability model in schizophrenia. Alternatively, other factors, such as self-efficacy, have been found to account for a significant amount of the variance in coping styles of individuals with schizophrenia, which may also be the case for CHR individuals.
To our knowledge, this is the first study to examine the relationship between coping styles with clinical symptomatology and psychosocial functioning in CHR individuals over time. These findings suggest that implementing interventions to teach adaptive coping styles and simultaneously reduce maladaptive coping styles in CHR individuals may also affect psychosocial functioning and clinical symptomatology. Identifying the coping strategies used by CHR individuals may aid in targeting specific interventions that may be useful in preventing the onset of psychosis.