First Impact Factor released in June 2010 and now listed in MEDLINE!
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Early Intervention in Psychiatry 2015; ••: ••–••
doi:10.1111/eip.12223
Original Article Coping and the stages of psychosis: an investigation into the coping styles in people at risk of psychosis, in people with first-episode and multiple-episode psychoses Mareike Kommescher, Sonja Gross, Verena Pützfeld, Joachim Klosterkötter and Andreas Bechdolf Abstract Aim: The concept of coping is central to recent models of psychosis. The aim of the present paper is to explore whether specific coping styles relate to certain stages of the disorder.
Department of Psychiatry and Psychotherapy, University of Cologne, Cologne, Germany Corresponding author: Ms Mareike Kommescher, Department of Psychiatry and Psychotherapy, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany. Email: [email protected] Received 21 July 2014; accepted 19 December 2014
Methods: Thirty-nine clients at clinical high risk (CHR) of first-episode psychosis, 19 clients with firstepisode psychosis and 52 clients with multiple-episode psychosis completed a Stress Coping Questionnaire. This questionnaire consists of 114 items defining one overall positive coping scale (with three subscales) and one negative coping scale. Analyses of variance with group as between-subject factor and coping behaviour as within-subject factor were used to identify different coping patterns. Results: On the level of subscales no group differences could be detected, but analysis of variance revealed
Conclusions: The overall coping styles were similar across the different stages of psychosis. However, at-risk persons presented especially pronounced negative coping and a small range of strategies, indicating a specific need for psychosocial support in this stage of the disorder.
Key words: coping, first-episode schizophrenia, high-risk research, prodrome, schizophrenia.
INTRODUCTION The vulnerability-stress coping model1 is central to recent models of genesis and treatment of psychosis. According to this model, when vulnerable individuals face stressful events (life events and/or daily hassles) that they are unable to cope with, this leads to a ‘decompensation’ (first episode or relapse). Guided by such a model, psychotherapeutic interventions often focus on stress management and/or attempt to improve individual coping abilities. © 2015 Wiley Publishing Asia Pty Ltd
slightly different patterns: CHR clients used significantly more negative than positive coping styles (P = 0.001), followed by patients with multipleepisode psychosis (P = 0.074). Firstepisode patients were most likely to use negative as well as positive coping (P = 0.960). Across all stages of illness, stress control was significantly preferred compared to the other positive coping styles distraction and devaluation. Again, this pattern was especially pronounced for at-risk clients and patients with multiple-episode psychosis, whereas patients with firstepisode psychosis were most likely to use devaluation as well as distraction.
In their clinical staging model for psychiatric disorders, McGorry et al.2 postulate a heuristic model of progression of psychiatric disorders through stages of severity (0–4). In psychotic disorders, stages 0–1 correspond to individuals with an increased risk for developing a psychotic episode; stage 2 is the first episode of threshold disorder; stage 3 is characterized by incomplete remission and/or relapse(s); and stage 4 describes a severe and persistent state of illness. According to this staging model, ‘biological and personal risk factors influence the progression 1
Coping and the stages of psychosis from one stage to the next (. . .), while some risk factors may operate across several or all stage transitions, others may be stage-specific’.2 This model also raises the question of whether coping strategies and the stages of psychosis are correlated or whether coping is a personal factor that is stable across all stages of the illness and constitutes a part of the vulnerability for psychosis. Additionally, individuals at clinical high risk (CHR) of psychosis may show different coping strategies than people with first or multiple-episode psychosis (MEP). Most of the studies so far have been performed on coping strategies used by individuals with exacerbated psychotic episodes, using a broad range of instruments and classification strategies to assess individual coping behaviour. Whereas most studies addressed symptom-related coping, fewer studies have focused on general coping strategies.3 The overall results of this research are heterogeneous. For symptom-related coping, there is some evidence that a wider range (number) of coping strategies are likely to be associated with better symptom handling and a better outcome.4,5 Data on the most effective type of coping are inconsistent. Whereas some authors found problem-focused coping to be more effective than emotion-focused coping,6 other studies showed the opposite or failed to find any association between preferred type of coping and outcome.7,8 Studies focusing on general coping revealed similarly inconsistent results. Brenner et al.9 reported that patients with psychosis used more problem solving than patients with other psychiatric disorders and healthy controls. However, van den Bosch et al.10 reported less problem solving compared with healthy controls. Jansen et al.11 found less active coping and more passive coping along with avoidance strategies among patients with psychosis than in healthy controls. Ventura et al.12 reported that patients with first-episode psychosis (FEP) used less ‘approach’ coping responses (logical analysis, positive reappraisal, seeking guidance/ support, problem solving) as well as cognitively and behaviourally oriented coping strategies than controls but found no difference in the use of avoidance coping strategies (cognitive avoidance, acceptance or resignation, seeking alternative rewards, emotional discharge). So far, limited data have been reported on coping in individuals at high risk of psychosis. Schuldberg et al.13 found that hypothetically psychosis-prone individuals (‘Per-Mag subjects’: non-clinical subjects who reported sub-threshold perceptional aberrations and/or magical thinking in the Per-Mag Scale by Eckblad & Chapman)14 reported higher 2
‘accepting responsibility’ and ‘escape-avoidance’ and less ‘search for social support’ than healthy controls. Dangelmaier et al.15, who also compared PerMag subjects with healthy controls, found higher rates of non-adaptive coping and negative social support in these individuals. Krabbendam et al.16 reported that individuals, reacting to initial psychotic or psychosis-like experiences with a symptomatic coping style, had an increased risk for developing clinical psychosis, whereas those who reacted with other coping styles (active problem solving, passive illness behaviour, active and passive problem avoiding) were not associated with a greater risk of transition. All three studies examined non-clinical subjects and the transfer of these findings to individuals at high risk of psychosis might therefore be critical. Philipps3 found that people at risk of psychosis felt more distressed and less able to cope with stressors than healthy controls and that they were also more likely to utilize emotionfocused coping strategies whereas healthy controls were more likely to use task-focused coping strategies and avoidance in terms of social diversion. Lee et al. 17 found that at-risk persons relied significantly more on tension-reduction coping strategies as compared to healthy controls and that their coping behaviour was similar to those of people with recent-onset schizophrenia. Schmidt et al.18 compared CHR patients with patients with FEP and found deficits in coping strategies (assessed by the Stress Coping Questionnaire, SCQ), self-efficacy and control beliefs in both groups. Pruessner et al.19 reported significantly higher stress levels in individuals at ultra-high risk of psychosis compared to first-episode patients and lower social support and active coping compared to healthy controls. In summary, the findings concerning individuals with established psychosis are heterogeneous and limited data are available for individuals at high risk of psychosis. Moreover, studies used different instruments and categories to describe coping behaviour. As far as we know, no study has yet compared coping strategies of people at CHR of psychosis with those of first-episode and multiple-episode patients. The aim of the present study is therefore to explore general coping behaviour in CHR subjects in comparison with individuals with established first- or MEP. METHODS Participants Thirty-nine CHR subjects were recruited from consecutive referrals to the Cologne Early Recognition © 2015 Wiley Publishing Asia Pty Ltd
M. Kommescher et al. TABLE 1. Definition of subjects at clinical high risk (CHR) of psychosis – criteria of the early initial prodromal state (EIPS) Inclusion criteria: Self-experienced cognitive thought and perception deficits (basic symptoms): One or more of the following basic symptoms in the last 3 months several times a week: • Thought interferences • Thought perseveration • Thought pressure • Thought blockages • Disturbances of receptive language, either heard or read • Decreased ability to discriminate between ideas and perception, fantasy and true memories • Unstable ideas of reference (subject-centrism) • Derealization • Visual perception disturbances (blurred vision, transitory blindness, partial sight, hypersensitivity to light, etc.) • Acoustic perception disturbances (hypersensitivity to sounds or noise, acoasms, etc.) or Reduction in the Global Assessment of Functioning Score (DSM IV) of at least 30 points (within the past year) and at least one of the following risk factors: • First-degree relative with a lifetime diagnosis of schizophrenia • Or a schizophrenia spectrum disorder • Pre- or perinatal complications Exclusion criteria: Attenuated or transient positive symptoms Present or past diagnosis of a schizophrenic, schizophreniform, schizoaffective, delusional or bipolar disorder according to DSM IV Present or past diagnosis of a brief psychotic disorder according to DSM IV with a duration of more than 1 week or within the last 4 weeks regardless of its duration Diagnosis of delirium, dementia, amnestic or other cognitive disorder, mental retardation, psychiatric disorders due to a somatic factor or related to the consumption of psychotropic substances according to DSM IV Alcohol or drug abuse within the last 3 months prior to inclusion according to DSM IV Diseases of the central nervous system (inflammatory, traumatic, epilepsy, etc.) Aged below 17 and above 35 years
and Intervention Centre for mental crises (FETZ) at the Department of Psychiatry and Psychotherapy at the University of Cologne, Germany, between July 2000 and February 2003. The centre is a specially designed outpatient department, aiming to provide support in a non-stigmatizing environment to help-seeking young people suffering from possible prepsychotic symptoms. All CHR subjects met the criteria defining the early initial prodromal state – EIPS (Table 1). More details concerning the development of these criteria are presented in earlier studies.20–22 CHR was defined by: (i) the presence of certain self-experienced deficits in cognition and perception and/or (ii) by the presence of a clinically relevant decline of functioning in combination with well-established risk factors.23 The deficits in cognition and perception are based on the concept of ‘basic symptoms’,24 which were prospectively found to predict transition to psychosis.25 All CHR subjects gave informed consent to participate in a randomized controlled psychological intervention trial20,26,27 and were assessed at the time of entering the trial. Nineteen patients with a FEP and 52 patients with MEP were recruited from consecutive admissions to © 2015 Wiley Publishing Asia Pty Ltd
the inpatient unit of the Department of Psychiatry and Psychotherapy of the University of Cologne between July 1999 and December 2000. All patients gave informed consent to participate in a psychological intervention trial.28,29 Participants with FEP and MEP had to be aged between 18 and 40 years and meet the criteria for first or multiple episode of schizophrenia or a schizoaffective disorder (DSM IV 295.1-3, 295.5-9).30 At the time of assessment, most patients were in partial remission from an acute episode of psychosis and all participants were receiving psychotropic medication on an individual basis. Measures Demographic data were collected using a brief interview and from charts. Coping strategies were assessed using the SCQ.31 This self-report questionnaire was based on the coping model developed by Lazarus32 and designed to assess coping behaviour in regard to several stressors. It consists of 120 items on a 5-point scale defining three positive coping subscales, one overall positive subscale and one negative coping subscale. Coping strategies such as 3
Coping and the stages of psychosis trivialization, downplaying by comparison with others and guilt defence were defined as devaluation (POS1) and can therefore be summarized as cognitive coping. Coping strategies such as diversion from situations, vicarious satisfaction, search for self-affirmation and relaxation were called distraction (POS2), which can be summarized as emotion-focused coping. Coping strategies like situation control, reaction control and positive selfinstructions were defined as stress control (POS3). Overall positive coping (POS) includes all positive subscales. Escape, social withdrawal, continued mental preoccupation, resignation, self-pity and self-accusation define the overall negative coping subscale (NEG). Internal consistencies of the aggregated positive and negative strategies ranged from 0.84 to 0.94.31 Predictive basic symptoms were observer rated using the symptom list of the Early Recognition Inventory and Interview for the Retrospective Assessment of the Onset of Schizophrenia – ERIraos.33 This instrument was specially designed for the assessment of prodromal symptoms and consists of 110 items covering 12 categories. Interrater reliability (kappa) values for ‘symptoms present in the year before interview’ were between 0.41 and 0.87.34 Psychopathology was observer rated using the Positive and Negative Syndrome Scale (PANSS).35 For further analysis, we used the positive syndrome (PANSS P), negative syndrome (PANSS N) and general psychopathology (PANSS G) subscales. A depression score was derived from PANSS items anxiety (G2), depression (G6), guilty feelings (G3) and tension (G4) in accordance withWolthaus et al.36 This score was found to correlate with MADRS37 depression scores (r = 0.87) in patients with FEP. Data analyses Data were analysed using the Statistical Package for Social Sciences – SPSS 16.0 for Mac (2007).38 Sample characteristics were analysed using t-tests or χ2 tests to check for differences between subgroups. Raw data distribution of SCQ subscales did not differ significantly from normal distribution indicated by Kolmogrov–Smirnov tests. Thereafter, one-way anovas with Bonferroni post hoc tests were applied to examine the mean SCQ scores between EIPS, FEP and MEP subgroups. Results will be reported without Bonferroni adjustment for multiple testing, as it did not change the results. In order to identify different coping patterns between the three samples, an analysis of variance with group as between-subject factor (EIPS, FEP, MEP) and coping behaviour 4
as within-subject factor was used. Exploratory bivariate correlations (Pearson’s coefficients) with two-tailed tests of significance were calculated between SCQ dimensions and psychopathology scores. RESULTS Sample characteristics Thirty-nine CHR subjects, 19 patients with FEP and 52 patients with MEP were included in the study (Table 2). Participants with FEP were slightly but not significantly older than those at CHR (28.21 vs. 24.74 years). In line with expectations, patients of the MEP sample were significantly older than the participants of the two other diagnostic groups (34.71 years). About two-thirds of the CHR and FEP samples were male, whereas the ratio of women and men in the MEP was balanced. Overall, there were no significant differences between subgroups in gender distribution. All three groups were quite highly educated (12.44, 11.95 and 11.56 years of education). As could be expected, CHR patients were significantly higher educated than MEP patients. Most participants in all groups were single. In the CHR group fewer persons were single, but this difference was not statistically significant. The employment status differed significantly between the groups: participants with MEP (48.1%) showed the highest unemployment rate followed by FEP patients (36.8%). In CHR (69.2%) and FEP (42.1%), most participants remained in schools, universities or other educational settings. FEP and MEP patients showed significantly higher positive and negative PANSS scores, MEP patients also showed higher general psychopathology scores than participants at CHR, whereas depression scores did not differ significantly between the three samples. SCQ Group differences Descriptive statistics for the positive (POS) and the negative (NEG) scales of the SCQ as well as for the three positive subscales devaluation (POS1), distraction (POS2) and stress control (POS3) for the three subgroups are presented in Table 3. Table 4 shows the results of the group comparisons between CHR, FEP and MEP. On a descriptive level, patients at CHR showed the highest scores on the negative subscale and the lowest scores on the positive subscale. Concerning the three subscales, the CHR sample showed the lowest scores of devaluation and © 2015 Wiley Publishing Asia Pty Ltd
M. Kommescher et al. TABLE 2. Sample characteristics for subjects at clinical high risk (CHR) of psychosis, and patients with first-episode psychosis (FEP) and multiple-episode psychosis (MEP)
Age, years (mean (SD)) Gender (n (%)) Female Male Years of education (mean (SD)) Marital status (n (%)) Married, cohabitation Living alone, divorced, widowed Unknown Employment status (n (%)) Employed (full-/part-time) Training/retraining Unemployed Other/unknown PANSS (mean (SD)) Positive Negative General Depression
CHR (n = 39)
FEP (n = 19)
MEP (n = 52)
CHR versus FEP (P-values)
CHR versus MEP (P-values)
24.74 (4.71)
28.21 (9.24)
34.71 (10.55)
0.468
12 (30.8) 27 (69.2) 12.44 (1.08)
7 (36.8) 12 (63.2) 11.95 (1.43)
26 (50.0) 26 (50.0) 11.56 (1.64)
0.767*
0.086*
0.423*
0.703
0.021
0.963
8 (20.5) 29 (74.4) 2 (5.1)
2 (10.5) 17 (89.5) 0 (0.0)
8 (15.4) 44 (84.6) 0 (0.0)
0.353**
0.193**
0.602**
5 (12.8) 27 (69.2) 3 (7.7) 4 (10.3)
3 (15.8) 8 (42.1) 7 (36.8) 1 (5.3)
7 (13.5) 4 (7.7) 25 (48.1) 16 (30.8)
0.040**
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Early Intervention in Psychiatry 2015; ••: ••–••
doi:10.1111/eip.12223
Original Article Coping and the stages of psychosis: an investigation into the coping styles in people at risk of psychosis, in people with first-episode and multiple-episode psychoses Mareike Kommescher, Sonja Gross, Verena Pützfeld, Joachim Klosterkötter and Andreas Bechdolf Abstract Aim: The concept of coping is central to recent models of psychosis. The aim of the present paper is to explore whether specific coping styles relate to certain stages of the disorder.
Department of Psychiatry and Psychotherapy, University of Cologne, Cologne, Germany Corresponding author: Ms Mareike Kommescher, Department of Psychiatry and Psychotherapy, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany. Email: [email protected] Received 21 July 2014; accepted 19 December 2014
Methods: Thirty-nine clients at clinical high risk (CHR) of first-episode psychosis, 19 clients with firstepisode psychosis and 52 clients with multiple-episode psychosis completed a Stress Coping Questionnaire. This questionnaire consists of 114 items defining one overall positive coping scale (with three subscales) and one negative coping scale. Analyses of variance with group as between-subject factor and coping behaviour as within-subject factor were used to identify different coping patterns. Results: On the level of subscales no group differences could be detected, but analysis of variance revealed
Conclusions: The overall coping styles were similar across the different stages of psychosis. However, at-risk persons presented especially pronounced negative coping and a small range of strategies, indicating a specific need for psychosocial support in this stage of the disorder.
Key words: coping, first-episode schizophrenia, high-risk research, prodrome, schizophrenia.
INTRODUCTION The vulnerability-stress coping model1 is central to recent models of genesis and treatment of psychosis. According to this model, when vulnerable individuals face stressful events (life events and/or daily hassles) that they are unable to cope with, this leads to a ‘decompensation’ (first episode or relapse). Guided by such a model, psychotherapeutic interventions often focus on stress management and/or attempt to improve individual coping abilities. © 2015 Wiley Publishing Asia Pty Ltd
slightly different patterns: CHR clients used significantly more negative than positive coping styles (P = 0.001), followed by patients with multipleepisode psychosis (P = 0.074). Firstepisode patients were most likely to use negative as well as positive coping (P = 0.960). Across all stages of illness, stress control was significantly preferred compared to the other positive coping styles distraction and devaluation. Again, this pattern was especially pronounced for at-risk clients and patients with multiple-episode psychosis, whereas patients with firstepisode psychosis were most likely to use devaluation as well as distraction.
In their clinical staging model for psychiatric disorders, McGorry et al.2 postulate a heuristic model of progression of psychiatric disorders through stages of severity (0–4). In psychotic disorders, stages 0–1 correspond to individuals with an increased risk for developing a psychotic episode; stage 2 is the first episode of threshold disorder; stage 3 is characterized by incomplete remission and/or relapse(s); and stage 4 describes a severe and persistent state of illness. According to this staging model, ‘biological and personal risk factors influence the progression 1
Coping and the stages of psychosis from one stage to the next (. . .), while some risk factors may operate across several or all stage transitions, others may be stage-specific’.2 This model also raises the question of whether coping strategies and the stages of psychosis are correlated or whether coping is a personal factor that is stable across all stages of the illness and constitutes a part of the vulnerability for psychosis. Additionally, individuals at clinical high risk (CHR) of psychosis may show different coping strategies than people with first or multiple-episode psychosis (MEP). Most of the studies so far have been performed on coping strategies used by individuals with exacerbated psychotic episodes, using a broad range of instruments and classification strategies to assess individual coping behaviour. Whereas most studies addressed symptom-related coping, fewer studies have focused on general coping strategies.3 The overall results of this research are heterogeneous. For symptom-related coping, there is some evidence that a wider range (number) of coping strategies are likely to be associated with better symptom handling and a better outcome.4,5 Data on the most effective type of coping are inconsistent. Whereas some authors found problem-focused coping to be more effective than emotion-focused coping,6 other studies showed the opposite or failed to find any association between preferred type of coping and outcome.7,8 Studies focusing on general coping revealed similarly inconsistent results. Brenner et al.9 reported that patients with psychosis used more problem solving than patients with other psychiatric disorders and healthy controls. However, van den Bosch et al.10 reported less problem solving compared with healthy controls. Jansen et al.11 found less active coping and more passive coping along with avoidance strategies among patients with psychosis than in healthy controls. Ventura et al.12 reported that patients with first-episode psychosis (FEP) used less ‘approach’ coping responses (logical analysis, positive reappraisal, seeking guidance/ support, problem solving) as well as cognitively and behaviourally oriented coping strategies than controls but found no difference in the use of avoidance coping strategies (cognitive avoidance, acceptance or resignation, seeking alternative rewards, emotional discharge). So far, limited data have been reported on coping in individuals at high risk of psychosis. Schuldberg et al.13 found that hypothetically psychosis-prone individuals (‘Per-Mag subjects’: non-clinical subjects who reported sub-threshold perceptional aberrations and/or magical thinking in the Per-Mag Scale by Eckblad & Chapman)14 reported higher 2
‘accepting responsibility’ and ‘escape-avoidance’ and less ‘search for social support’ than healthy controls. Dangelmaier et al.15, who also compared PerMag subjects with healthy controls, found higher rates of non-adaptive coping and negative social support in these individuals. Krabbendam et al.16 reported that individuals, reacting to initial psychotic or psychosis-like experiences with a symptomatic coping style, had an increased risk for developing clinical psychosis, whereas those who reacted with other coping styles (active problem solving, passive illness behaviour, active and passive problem avoiding) were not associated with a greater risk of transition. All three studies examined non-clinical subjects and the transfer of these findings to individuals at high risk of psychosis might therefore be critical. Philipps3 found that people at risk of psychosis felt more distressed and less able to cope with stressors than healthy controls and that they were also more likely to utilize emotionfocused coping strategies whereas healthy controls were more likely to use task-focused coping strategies and avoidance in terms of social diversion. Lee et al. 17 found that at-risk persons relied significantly more on tension-reduction coping strategies as compared to healthy controls and that their coping behaviour was similar to those of people with recent-onset schizophrenia. Schmidt et al.18 compared CHR patients with patients with FEP and found deficits in coping strategies (assessed by the Stress Coping Questionnaire, SCQ), self-efficacy and control beliefs in both groups. Pruessner et al.19 reported significantly higher stress levels in individuals at ultra-high risk of psychosis compared to first-episode patients and lower social support and active coping compared to healthy controls. In summary, the findings concerning individuals with established psychosis are heterogeneous and limited data are available for individuals at high risk of psychosis. Moreover, studies used different instruments and categories to describe coping behaviour. As far as we know, no study has yet compared coping strategies of people at CHR of psychosis with those of first-episode and multiple-episode patients. The aim of the present study is therefore to explore general coping behaviour in CHR subjects in comparison with individuals with established first- or MEP. METHODS Participants Thirty-nine CHR subjects were recruited from consecutive referrals to the Cologne Early Recognition © 2015 Wiley Publishing Asia Pty Ltd
M. Kommescher et al. TABLE 1. Definition of subjects at clinical high risk (CHR) of psychosis – criteria of the early initial prodromal state (EIPS) Inclusion criteria: Self-experienced cognitive thought and perception deficits (basic symptoms): One or more of the following basic symptoms in the last 3 months several times a week: • Thought interferences • Thought perseveration • Thought pressure • Thought blockages • Disturbances of receptive language, either heard or read • Decreased ability to discriminate between ideas and perception, fantasy and true memories • Unstable ideas of reference (subject-centrism) • Derealization • Visual perception disturbances (blurred vision, transitory blindness, partial sight, hypersensitivity to light, etc.) • Acoustic perception disturbances (hypersensitivity to sounds or noise, acoasms, etc.) or Reduction in the Global Assessment of Functioning Score (DSM IV) of at least 30 points (within the past year) and at least one of the following risk factors: • First-degree relative with a lifetime diagnosis of schizophrenia • Or a schizophrenia spectrum disorder • Pre- or perinatal complications Exclusion criteria: Attenuated or transient positive symptoms Present or past diagnosis of a schizophrenic, schizophreniform, schizoaffective, delusional or bipolar disorder according to DSM IV Present or past diagnosis of a brief psychotic disorder according to DSM IV with a duration of more than 1 week or within the last 4 weeks regardless of its duration Diagnosis of delirium, dementia, amnestic or other cognitive disorder, mental retardation, psychiatric disorders due to a somatic factor or related to the consumption of psychotropic substances according to DSM IV Alcohol or drug abuse within the last 3 months prior to inclusion according to DSM IV Diseases of the central nervous system (inflammatory, traumatic, epilepsy, etc.) Aged below 17 and above 35 years
and Intervention Centre for mental crises (FETZ) at the Department of Psychiatry and Psychotherapy at the University of Cologne, Germany, between July 2000 and February 2003. The centre is a specially designed outpatient department, aiming to provide support in a non-stigmatizing environment to help-seeking young people suffering from possible prepsychotic symptoms. All CHR subjects met the criteria defining the early initial prodromal state – EIPS (Table 1). More details concerning the development of these criteria are presented in earlier studies.20–22 CHR was defined by: (i) the presence of certain self-experienced deficits in cognition and perception and/or (ii) by the presence of a clinically relevant decline of functioning in combination with well-established risk factors.23 The deficits in cognition and perception are based on the concept of ‘basic symptoms’,24 which were prospectively found to predict transition to psychosis.25 All CHR subjects gave informed consent to participate in a randomized controlled psychological intervention trial20,26,27 and were assessed at the time of entering the trial. Nineteen patients with a FEP and 52 patients with MEP were recruited from consecutive admissions to © 2015 Wiley Publishing Asia Pty Ltd
the inpatient unit of the Department of Psychiatry and Psychotherapy of the University of Cologne between July 1999 and December 2000. All patients gave informed consent to participate in a psychological intervention trial.28,29 Participants with FEP and MEP had to be aged between 18 and 40 years and meet the criteria for first or multiple episode of schizophrenia or a schizoaffective disorder (DSM IV 295.1-3, 295.5-9).30 At the time of assessment, most patients were in partial remission from an acute episode of psychosis and all participants were receiving psychotropic medication on an individual basis. Measures Demographic data were collected using a brief interview and from charts. Coping strategies were assessed using the SCQ.31 This self-report questionnaire was based on the coping model developed by Lazarus32 and designed to assess coping behaviour in regard to several stressors. It consists of 120 items on a 5-point scale defining three positive coping subscales, one overall positive subscale and one negative coping subscale. Coping strategies such as 3
Coping and the stages of psychosis trivialization, downplaying by comparison with others and guilt defence were defined as devaluation (POS1) and can therefore be summarized as cognitive coping. Coping strategies such as diversion from situations, vicarious satisfaction, search for self-affirmation and relaxation were called distraction (POS2), which can be summarized as emotion-focused coping. Coping strategies like situation control, reaction control and positive selfinstructions were defined as stress control (POS3). Overall positive coping (POS) includes all positive subscales. Escape, social withdrawal, continued mental preoccupation, resignation, self-pity and self-accusation define the overall negative coping subscale (NEG). Internal consistencies of the aggregated positive and negative strategies ranged from 0.84 to 0.94.31 Predictive basic symptoms were observer rated using the symptom list of the Early Recognition Inventory and Interview for the Retrospective Assessment of the Onset of Schizophrenia – ERIraos.33 This instrument was specially designed for the assessment of prodromal symptoms and consists of 110 items covering 12 categories. Interrater reliability (kappa) values for ‘symptoms present in the year before interview’ were between 0.41 and 0.87.34 Psychopathology was observer rated using the Positive and Negative Syndrome Scale (PANSS).35 For further analysis, we used the positive syndrome (PANSS P), negative syndrome (PANSS N) and general psychopathology (PANSS G) subscales. A depression score was derived from PANSS items anxiety (G2), depression (G6), guilty feelings (G3) and tension (G4) in accordance withWolthaus et al.36 This score was found to correlate with MADRS37 depression scores (r = 0.87) in patients with FEP. Data analyses Data were analysed using the Statistical Package for Social Sciences – SPSS 16.0 for Mac (2007).38 Sample characteristics were analysed using t-tests or χ2 tests to check for differences between subgroups. Raw data distribution of SCQ subscales did not differ significantly from normal distribution indicated by Kolmogrov–Smirnov tests. Thereafter, one-way anovas with Bonferroni post hoc tests were applied to examine the mean SCQ scores between EIPS, FEP and MEP subgroups. Results will be reported without Bonferroni adjustment for multiple testing, as it did not change the results. In order to identify different coping patterns between the three samples, an analysis of variance with group as between-subject factor (EIPS, FEP, MEP) and coping behaviour 4
as within-subject factor was used. Exploratory bivariate correlations (Pearson’s coefficients) with two-tailed tests of significance were calculated between SCQ dimensions and psychopathology scores. RESULTS Sample characteristics Thirty-nine CHR subjects, 19 patients with FEP and 52 patients with MEP were included in the study (Table 2). Participants with FEP were slightly but not significantly older than those at CHR (28.21 vs. 24.74 years). In line with expectations, patients of the MEP sample were significantly older than the participants of the two other diagnostic groups (34.71 years). About two-thirds of the CHR and FEP samples were male, whereas the ratio of women and men in the MEP was balanced. Overall, there were no significant differences between subgroups in gender distribution. All three groups were quite highly educated (12.44, 11.95 and 11.56 years of education). As could be expected, CHR patients were significantly higher educated than MEP patients. Most participants in all groups were single. In the CHR group fewer persons were single, but this difference was not statistically significant. The employment status differed significantly between the groups: participants with MEP (48.1%) showed the highest unemployment rate followed by FEP patients (36.8%). In CHR (69.2%) and FEP (42.1%), most participants remained in schools, universities or other educational settings. FEP and MEP patients showed significantly higher positive and negative PANSS scores, MEP patients also showed higher general psychopathology scores than participants at CHR, whereas depression scores did not differ significantly between the three samples. SCQ Group differences Descriptive statistics for the positive (POS) and the negative (NEG) scales of the SCQ as well as for the three positive subscales devaluation (POS1), distraction (POS2) and stress control (POS3) for the three subgroups are presented in Table 3. Table 4 shows the results of the group comparisons between CHR, FEP and MEP. On a descriptive level, patients at CHR showed the highest scores on the negative subscale and the lowest scores on the positive subscale. Concerning the three subscales, the CHR sample showed the lowest scores of devaluation and © 2015 Wiley Publishing Asia Pty Ltd
M. Kommescher et al. TABLE 2. Sample characteristics for subjects at clinical high risk (CHR) of psychosis, and patients with first-episode psychosis (FEP) and multiple-episode psychosis (MEP)
Age, years (mean (SD)) Gender (n (%)) Female Male Years of education (mean (SD)) Marital status (n (%)) Married, cohabitation Living alone, divorced, widowed Unknown Employment status (n (%)) Employed (full-/part-time) Training/retraining Unemployed Other/unknown PANSS (mean (SD)) Positive Negative General Depression
CHR (n = 39)
FEP (n = 19)
MEP (n = 52)
CHR versus FEP (P-values)
CHR versus MEP (P-values)
24.74 (4.71)
28.21 (9.24)
34.71 (10.55)
0.468
12 (30.8) 27 (69.2) 12.44 (1.08)
7 (36.8) 12 (63.2) 11.95 (1.43)
26 (50.0) 26 (50.0) 11.56 (1.64)
0.767*
0.086*
0.423*
0.703
0.021
0.963
8 (20.5) 29 (74.4) 2 (5.1)
2 (10.5) 17 (89.5) 0 (0.0)
8 (15.4) 44 (84.6) 0 (0.0)
0.353**
0.193**
0.602**
5 (12.8) 27 (69.2) 3 (7.7) 4 (10.3)
3 (15.8) 8 (42.1) 7 (36.8) 1 (5.3)
7 (13.5) 4 (7.7) 25 (48.1) 16 (30.8)
0.040**
