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Individuals with early psychosis have smaller social networks than individuals without psychosis (Macdonald, Hayes, & Baglioni, 2000). Studies examining factors associated with the reduction in social functioning in psychosis have focussed on the role of negative symptoms (Dickerson, Boronow, Ringel, & Parente, 1999), deficits in social cognitive skills (Penn, Sanna, & Roberts, 2008), attachment styles (Dozier, Stevenson, Lee, & Velligan, 1991), and stigma (Corrigan et al., 2005). Qualitative studies have also examined the experience of friendships early on in the course of psychosis, both from the perspective of the young person with psychosis (Macdonald, Sauer, Howie, & Albiston, 2005; Mackrell & Lavender, 2004) and more recently from the perspective of their friends (Brand, Harrop, & Ellett, 2011). Peer relationships are important for development in adolescence and early adulthood (Harrop & Trower, 2001, 2003), which is when psychosis most commonly emerges (Jablensky & Cole, 1997). Relatively little is known about the social networks of individuals early on in the course of psychosis; social rank theory provides a useful framework within which to consider this.
According to Social Rank Theory, emotions and moods are significantly influenced by perceptions of one's social status or rank, that is, the degree to which one feels inferior to others (Gilbert, 2000). Through social comparisons, such as comparisons of strength and power, social attractiveness, and perceived belonging to a social group, social ranks are formed (Gilbert & Allan, 1998). Social rank is important in being accepted by a social group; low social rank can result in engagement in submissive behaviours towards higher ranking others, such as passivity, appeasement, and compliance, and can also lead to feelings of entrapment, that is, feeling unable to control or escape from certain situations (Allan & Gilbert, 1997). For young people in particular, social rank within the peer group is important, as this is a time when peer relationships tend to replace attachment to parents (Harrop & Trower, 2001, 2003).
Social rank theory has also been applied to psychosis, and several studies have shown that individuals with psychosis tend to see themselves as inferior to others. In particular, loss of social role and appraisals of entrapment in individuals with psychosis have been found to be persistent over time, and individuals who were depressed felt greater entrapment and loss in relation to their psychosis (Rooke & Birchwood, 1998). In addition, individuals with early onset psychosis with comorbid social anxiety reported greater shame about their illness, felt that others viewed them as inferior, and felt entrapped by their illness (Birchwood et al., 2006). Furthermore, individuals who felt inferior and subordinate in relation to their voices also felt inferior and subordinate in relation to others (Birchwood, Meaden, Trower, Gilbert, & Plaistow, 2000).
There are a number of reasons why social rank theory might be relevant in early psychosis, particularly when examining peer groups: (1) peer groups provide a reference point for social comparisons and allow individuals to evaluate themselves in comparison to others (Brown & Lohr, 1987) and it is well known that the onset of psychosis results in reduced peer networks (Macdonald et al., 2000) and impacts on the quality of friendships (Brand et al., 2011); (2) the individual will experience for the first time the stigma of diagnosis, and a potential challenge to their perceived social acceptance (Birchwood, 2003; Birchwood et al., 2006); (3) individuals with psychosis often appraise themselves as socially unattractive (Birchwood, Mason, MacMillan, & Healy, 1993, 2000) and of low personal worth (Corrigan & Kleinlein, 2005); (4) the onset of psychosis has been associated with loss of perceived social standing, shame, adverse social identity, and fear of stigma (Birchwood, 2003); and (5) an individual may feel entrapped (inability to control or escape) by their symptoms (Birchwood et al., 1993).
Perceived peer group rank has not been examined before in an early psychosis sample. Therefore, in our study, we use social rank theory to understand how individuals with early psychosis evaluate themselves in relation to their peer group. Two hypotheses were tested: (1) size and quality of peer network, and social rank constructs (social comparison, submissive behaviour, and entrapment), will be associated with psychotic symptoms; and (2) individuals with early psychosis will have lower perceived social status, engage in submissive behaviours more frequently, and will feel more entrapped by external events compared to a healthy control group.
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The findings indicate that individuals with early psychosis have smaller social networks than matched controls, confirming the findings of previous studies (Macdonald et al., 2000). In terms of relationship qualities, individuals with early psychosis reported feeling less satisfied with, and more excluded by, their peer group compared with healthy controls. Given the cross-sectional design of the study, it is unclear whether these findings are reflective of a transient state, or whether they reflect perceptions of peer groups that were more entrenched. In addition, social network size was not found to be associated with psychotic or affective symptoms. Lack of an association between symptoms and size of network may be in part due to the way in which network size was measured in the current study. Another possibility is that size of network is associated with other variables not measured in this study, but which are known to be important in early psychosis, such as shame, fear of stigma, and diminished self-esteem (Birchwood et al., 1993; Corrigan & Kleinlein, 2005). Alternatively, symptoms might be associated with changes in network size or it could be that network size is small prior to the first onset of psychosis. The findings clearly need to be replicated and extended using a longitudinal design, and suggest the need for social outcomes in early psychosis to be measured in terms of the quality of relationships, as well as quantity of social contacts. This is consistent with the argument that current outcome measures do not encompass outcomes relevant to recovery in social domains (Shrivastava, Johnston, Shah, & Bureau, 2010).
The findings suggest that individuals with early psychosis viewed themselves of lower social rank and inferior compared to a matched control group, engaged in submissive behaviour more frequently, and reported being more entrapped by events. This is consistent with the findings of other studies of social rank in both individuals with depression (Allan & Gilbert, 1995) and those with first episode psychosis (Birchwood et al., 2000); however, the current study is unique in that it targets how people saw their own rank specifically with regard to peers, not rank in general (and therefore not including rank with parents and/or siblings). This is important as part of an increased research effort on peer relationships in early psychosis (Brand et al., 2011) and is also clinically important because improving same-age social contact and work is increasingly important in preventing relapse (Jolley et al., 2006).
Social rank constructs were also found to be associated with positive psychotic symptoms. Therefore, it is important to consider both the size of the social network and how individuals evaluate themselves in relation to their peers. Placing the findings in their evolutionary context, it has been argued that individuals will be aware of their low rank and lack of power to protect themselves when in adverse environments (Birchwood et al., 2006). Responses to such environments can include the activation of defensive emotions and strategies (Brown, Harris, & Hepworth, 1995; Gilbert, 2004), such as social anxiety (Gilbert, 2002) and paranoia (Ellett, Allen-Crooks, Stevens, Wildschut, & Chadwick, 2012; Ellett & Chadwick, 2007; Ellett, Lopes, & Chadwick, 2003; Kelleher, Jenner, & Cannon, 2010). Future longitudinal studies will allow testing of the predictive value of social rank in peer groups in relation to symptom progression.
It is important to note that our study can only comment on perceived social rank amongst individuals with early psychosis. Although this is likely to be influenced by the presence of psychotic and/or affective symptoms, such as paranoia or low mood, low rank with regards to friends might also be a mechanism whereby individuals avoid their friends and lose friendships. Future research might usefully examine how an individual's social rank is perceived by their peers, thereby utilizing both subjective and objective assessments of social rank, and determine how this impacts on friendships. This is consistent with the call for greater direct involvement of friends, both in research and clinical interventions for individuals with early psychosis (Brand et al., 2011).
Our study has several limitations, which need to be considered when interpreting the findings. The calculation of peer network size employed limited participants to 10 network members. Although this method of measurement has been used in previous studies (e.g. Kuttler & La Greca, 2004) including in those with early psychosis (Macdonald et al., 2000), it could result in under-reporting, particularly for larger networks. In addition, analysing social network at one time point is a limitation; examining changes in network size over time would also be important. The study would have been strengthened had it also included a measure of functioning, such as the Social Functioning Scale (Birchwood, Smith, Cochrane, Wetton, & Copestake, 1990), a measure of adverse life events, and a formal diagnostic screening tool for control participants. Related to this, the sole reliance on self-report questionnaires as measures of all the key constructs, including social rank, was a considerable limitation, although this was addressed by reporting of internal consistency for all social rank variables. Future studies might consider some of the non-self-report approaches used in the peer literature, although these are typically applied to studies of school-age participants. Finally, the cross-sectional nature of the study means that no conclusions regarding causality can be made.
The findings have important clinical implications for individuals with early psychosis. Whilst functional recovery remains a major challenge for clinicians (Addington & Gleeson, 2005), the findings are consistent with the recognition that focusing solely on reducing psychotic and affective symptoms is unlikely to result in improvements in social functioning. It is important that individuals have ‘meaningful social contact’ with others (Penn et al., 2004), and there is a recognition that psychological interventions, such as Cognitive Behaviour Therapy, may need to be refined to enhance outcome in the first episode (Theodore et al., 2012). CBT already focuses explicitly on the perceived power and rank of voices (Chadwick and Birchwood, 1994), and power relationships with parents (family interventions), but the evidence here suggests that status and perceived power of peers is clearly an important but neglected intervention topic. Techniques might include considering evidence for and against peers having higher status; elaborating on the qualities of being down rank, such as whether it appears peers have omniscience or omnipotence (in those more unwell); and social skills training (Trower, 1984) to help people display higher status behaviours. Finally, Brand et al. (2011) have suggested 'peer interventions' with friends, and our group is currently working on these.