Original Paper Psychopathology 2015;48:11–17 DOI: 10.1159/000363144
Received: December 12, 2012 Accepted after revision: April 18, 2014 Published online: September 9, 2014
Coping with Delusions in Schizophrenia and Affective Disorder with Psychotic Symptoms: The Relationship between Coping Strategies and Dimensions of Delusion Sarah Rückl a Nana Christina Gentner a Liesa Büche a Matthias Backenstrass a, c Andreas Barthel b Helmut Vedder b Martin Bürgy c Klaus-Thomas Kronmüller a, d
Department of Psychiatry, University of Heidelberg, Heidelberg, b Psychiatric Center Nordbaden, Wiesloch, Center of Mental Health, Bürgerhospital, Stuttgart, and d Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, LWL Clinic Gütersloh, Gütersloh, Germany c
Key Words Affective disorder · Coping · Delusion · Schizophrenia
Abstract Background: Self-generated coping strategies and the enhancement of coping strategies are effective in the treatment of psychotic symptoms. Evaluating these strategies can be of clinical interest to develop better coping enhancement therapies. Cognitive models consider delusions as multidimensional phenomena. Using a psychometric approach, the relationship between coping and the dimensions of delusion were examined. Methods: Thirty schizophrenia spectrum patients with delusions and 29 patients with affective disorder with psychotic symptoms were interviewed using the Heidelberg Coping Scales for Delusions and the Heidelberg Profile of Delusional Experience. Analyses of variance were conducted to investigate differences between the groups, and Spearman’s rank-based correlations were used to examine the correlations between coping factors and the dimensions of delusion. Results: Schizophrenia spectrum patients used more medical care and symptomatic coping, whereas patients with affective disorder en-
© 2014 S. Karger AG, Basel 0254–4962/14/0481–0011$39.50/0 E-Mail [email protected] www.karger.com/psp
gaged in more depressive coping. In the schizophrenia spectrum sample, the action-oriented, the cognitive, and the emotional dimensions of delusion were related to coping factors. In patients with affective disorder, only the actionoriented dimension was related to coping factors. Conclusion: Patients with schizophrenia and affective disorder cope differently with delusions. The dimensions of delusion are related to coping and should be regarded when using cognitive therapy approaches to enhance coping strategies. © 2014 S. Karger AG, Basel
Introduction
Previous research has demonstrated that both selfgenerated coping strategies [1–6] and cognitive-behavioral interventions that enhance coping strategies [7–11] are effective in the treatment of psychotic symptoms, such as delusions and hallucinations [10]. Given that over half of patients with schizophrenia have persistent or recurring delusions despite antipsychotic treatment [12, 13], examining how patients cope with delusions is of great importance. Understanding these coping strategies Sarah Rückl Department of Psychiatry University of Heidelberg Vossstrasse 4, DE–69115 Heidelberg (Germany) E-Mail sarah.rueckl @ med.uni-heidelberg.de
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a
12
Psychopathology 2015;48:11–17 DOI: 10.1159/000363144
corporated in a psychometric approach to examine the relationships between coping and the action-oriented, cognitive, and emotional dimensions of delusion. Methods Participants Thirty patients with schizophrenia spectrum disorders experiencing delusions and 29 patients with an affective disorder with psychotic symptoms in the form of delusions participated in this study. All of the participants were receiving in-patient treatment at the Department of Psychiatry of the University of Heidelberg, the Psychiatric Center Nordbaden in Wiesloch, or the Center of Mental Health in Stuttgart. Patient diagnoses were determined through a structured clinical interview [26]. Exclusion criteria included severe medical conditions, neurological disorders, alcohol and drug dependency, and poor German language ability. This study was approved by the local ethics committee and was conducted in accordance with the ethical standards established by the Declaration of Helsinki [27]. The sample’s demographic characteristics are described in Results. Procedure The first step in this study was to contact the psychiatrist in charge to request consent for interviewing target patients. On first contact, an experimenter asked patients if they would like to participate in this study. Verbal and written information about the study was provided to each patient. Voluntary participation and anonymity were emphasized, and patients were informed that their participation would not influence the psychiatric and psychological treatment that they were receiving. After agreeing to participate in this study, patients were required to sign a written consent form. Data collection occurred within the context of a 45min interview with trained clinical psychologists or psychiatrists who had clinical experience. After a patient’s main delusional belief had been identified, the patient was informed that the interview would be about this specific delusional belief. Subsequently, the interviewer completed the Heidelberg Profile of Delusional Experience (unpubl. data). Then, patients were asked about the degree of distress that they experience with their delusional belief, and how much control they had over it. As lists of previously selected strategies can have the disadvantage of concealing strategies that were used successfully, patients were first encouraged to name all of the strategies that they used to manage their beliefs. This procedure assures an accurate assessment of the patient’s own experience with a symptom [2]. The answers were then divided and allocated into different categories; for example, if a patient said he isolates himself and avoids other people, this answer was classified as ‘social withdrawal’. It was also inquired as to how often each strategy was used. Then, patients were asked about the 33 predefined items of the Heidelberg Coping Scales for Delusions (HCSD). Finally, patients were asked to report their 3 most effective coping strategies. Instruments Coping strategies were assessed using the HCSD [28], which is an established instrument consisting of 33 coping strategies rated on a 5-point Likert scale ranging from ‘not at all’ to ‘very much.’
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in schizophrenia and affective disorder with psychotic symptoms can enhance therapeutic approaches to coping for patients who experience stress associated with delusions [14]. Yusupoff and Tarrier [10, p. 86] defined coping as ‘the active self-generation of cognitive and behavioral procedures either to impact the symptom directly or to minimize the resultant distress’. Lange [3] and Falloon and Talbot [4] published the first empirical studies on selfgenerated coping strategies in schizophrenia. The advantage of studying self-generated coping strategies is that patients are familiar with these strategies as they do not fall outside of the patients’ set of beliefs. These strategies allow patients to make sense of their own reality [15]. Lange [3] described the different coping behaviors of schizophrenic patients for managing the symptoms of schizophrenia, whereas Falloon and Talbot [4] focused on coping with hallucinations in schizophrenia. Both studies demonstrated that schizophrenic patients develop coping strategies to master their symptoms. This approach influenced future studies on coping, which have addressed questions regarding how patients cope with their disorders [2, 6, 14, 16–18], the prodromal phase [19], and their specific symptoms, including negative symptoms [20] and hallucinations [4, 21]. The results of these studies have indicated that patients with psychosis are actively involved in trying to manage their symptoms [2, 5, 6, 14, 16]. The use of several strategies has been associated with coping effectiveness [4, 5, 20]. Previous studies have reported that patients with schizophrenia apply cognitive strategies to cope with delusions and hallucinations [6, 16, 18], whereas behavioral strategies are used to deal with other symptoms, such as anxiety, depression, motor retardation, and thought disorders [6]. In spite of the amount of research examining coping, there is a lack of research focusing on coping with delusions. There is a definite need for studies comparing patients with schizophrenia and those with affective disorders with psychotic symptoms in the form of delusions. One study by van den Bosch and Rombouts [22] reported no differences between schizophrenic patients and patients with depression with regard to coping with problems and unpleasant situations. The aim of the present study was to compare the coping strategies used to deal with delusions in patients with schizophrenia and patients with affective disorder with psychotic symptoms. Recent cognitive models of delusions consider delusions to be multidimensional phenomena with cognitive, emotional, and action-oriented dimensions [23–25]. In the present study, cognitive models were in-
t tests were used to control for family-wise error. Associations were examined through Spearman’s rank-based correlations. p < 0.05 was considered statistically significant. All analyses were performed using SAS 9.12 (SAS Institute Inc., Cary, N.C., USA).
The HCSD also assesses the degree of distress caused by the delusional belief, the level of control over the delusional belief, and the 3 most effective strategies used to cope with delusions. Two coping indices were calculated to determine how many coping strategies the patients used and how often they used these strategies. The Coping Repertoire Index (CRI) calculates how many strategies the patients use, ranging from 0 (no strategy is used) to 33 (all of the strategies are used). The Coping Intensity Index (CII) is the sum of all of the ratings from all of the strategies (coping intensity; CI) divided by the number of strategies used by the patients. The factorstructure of the HCSD was examined using a principal component analysis with a varimax rotation, which yielded the following 5 factors: (1) resource-oriented coping (items: positive reevaluation, self-valorization, enjoyment, prosocial behavior, positive emotions, self-encouragement, humor, and searching for a meaning); (2) medical care (items: medical help, psychotherapy, trusting the therapist, medication compliance, disease acceptance, and information seeking); (3) distraction (items: alcohol and drug use, mental distraction, sensory distraction, distraction with specific activities, and distraction with unspecific activities); (4) cognitive coping (items: minimization, dissimulation, ignoring, controlling feelings, selfverbalization), and (5) depressive coping (items: social withdrawal, negative emotions, and resigning). The item for symptomatic coping was considered as a separate factor. Symptomatic coping has been defined as behaviors that are used to relieve discomfort, yet they often result in an increased expression of disorder-related behaviors [6]. The subscales showed internal consistency values ranging from α = 0.59 (cognitive coping) to α = 0.83 (resource-oriented coping). The interrater reliability was calculated using intraclass correlation coefficients, and the items showed values between ICC = 0.66 (resigning) and ICC = 0.96 (psychotherapy). Delusional belief and its dimensions were assessed with the Heidelberg Profile of Delusional Experience (unpubl. data), which is an established rating instrument used to assess and diagnose delusional beliefs in psychiatric disorders. A delusional belief was identified and classified according to the Association for Methodology and Documentation in Psychiatry [29], and 18 items were to assess delusion formal criteria. The factor-structure of the HPDE was examined using a principal component analysis with a varimax rotation, which yielded 3 factors [30]. The first factor was the action-oriented dimension and included the items of behavioral impact, pervasiveness of belief, preoccupation, and disruption in life caused by beliefs. The second factor was the cognitive dimension and included the items of conviction, perceptions of others’ views of beliefs, attempts to disprove beliefs, and insight into the delusional belief. The third factor was the emotional dimension and included negative and positive emotions and the distress associated with the delusional belief. The action-oriented dimension showed an internal consistency value of α = 0.78, and both the cognitive and the emotional dimensions had internal consistency values of α = 0.80. The interrater reliability was calculated using intraclass correlation coefficients and the items showed values between ICC = 0.71 (pervasiveness) and ICC = 0.92 (conviction) [31].
Sample In the schizophrenia spectrum disorder group, 22 of 30 patients (73.3%) had a diagnosis of schizophrenia, and 8 patients (26.7%) were diagnosed with schizoaffective disorder. Eleven participants were male (36.7%), and 19 participants were female (63.3%). The average age of this patient group was 46.96 years (SD = 12.21). Most patients were single (60%), 40% were employed, and 50% had less than 10 years of secondary education. These patients had experienced an average of 6 (SD = 7.17) hospital psychiatric treatments. Patients in this group scored an average of 67.5 points (SD = 10.23) on the PANSS total score. The mean level of global functioning, as measured by the Global Assessment of Function (GAF) scale [30], was 27 (SD = 5.68). In the affective disorder group, 28 of 29 patients (96.6%) had unipolar depression and were diagnosed with a severe depressive episode with psychotic symptoms at the time of the investigation. One patient (3.4%) had a bipolar disorder and presented a severe depressive episode with psychotic symptoms. The mean age of the 11 male (38.0%) and 18 female (62.0%) participants with affective disorder was 47.24 years (SD = 12.88). Most patients in this group (65.5%) were married or lived in a partnership, 44.8% were employed, and 55.1% had more than 10 years of secondary education. The mean number of hospital psychiatric treatments was 2.86 (SD = 1.88). Patients with affective disorder scored an average of 67.80 points (SD = 11.95) on the PANSS total score. The level of global functioning in this group of patients averaged 30.96 on the GAF (SD = 11.05). Differences between the groups were examined with one-way ANOVA, and patients with schizophrenia spectrum disorder had a greater number of hospital psychiatric treatments compared to patients with affective disorder (table 1). There were no differences between the groups with regard to age, GAF scores, or PANSS total scores.
Statistical Analysis One-way analyses of variance (ANOVA) were conducted to identify differences between the patients with schizophrenia spectrum disorders experiencing delusions and the patients with affective disorder with psychotic symptoms in the form of delusions. Bonferroni
Distress Associated with a Delusional Belief, Control over the Belief, and Coping Patients with affective disorders scored significantly higher on ratings of distress associated with a delusional
Delusions in Schizophrenia and Affective Disorder with Psychotic Symptoms
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Results
Table 1. Sociodemographic and psychopathological characteristics of the sample (n = 60)
Age, years Mean SD (range) Sex, n (%) Male Female Family situation, n (%) Single Married/partnership Divorced/widowed Secondary education, n (%) ≤10 years >10 years Employment situation, n (%) Employed Unemployed Retired Other GAF Mean SD (range) Psychiatric treatments Mean SD (range) PANSS total score Mean SD (range)
Affective disorder patients (n = 29)
F(2,58)
p
46.96 12.21 (22–66)
47.24 12.88 (23–71)
0.50
0.60
11 (36.7) 19 (63.3)
11 (38.0) 18 (62.0)
18 (60.0) 6 (20.0) 6 (20.0)
6 (20.7) 13 (44.8) 10 (34.5)
15 (50.0) 15 (50.0)
11 (37.9) 18 (62.1)
12 (40.0) 2 (6.6) 11 (36.7) 5 (16.7)
13 (44.8) 7 (24.1) 7 (24.1) 2 (7.0)
27.0 5.68 (15–50)
30.9 11.05 (18–68)
1.69
0.19
6.00a 7.17 (1–27)
2.86 1.88 (1–8)
5.16
0.02
67.50 10.23 (51–101)
67.80 11.95 (46–93)
0.01
0.92
> affective disorder.
belief and used more depressive coping to cope with delusion compared to the schizophrenia spectrum disorder patients, who used significantly more medical care and symptomatic coping (table 2). Relationships between the Dimensions of Delusion and Coping Factors For the schizophrenia spectrum disorder sample, the action-oriented dimension correlated significantly and negatively with cognitive coping. The cognitive dimension of delusion correlated significantly and negatively with resource-oriented coping, cognitive coping, and the CRI. Moreover, the emotional dimension of the delusional belief showed a significant positive correlation with depressive coping. For the sample of patients with affective disorder, the action-oriented dimension of the delusional belief correlated significantly and negatively with resource-oriented coping, cognitive coping, and the CII (tables 3, 4). 14
Psychopathology 2015;48:11–17 DOI: 10.1159/000363144
Discussion
Patients with schizophrenia used more medical care and symptomatic coping than patients with affective disorder, who were more likely to use depressive coping to deal with their delusional beliefs. These findings suggest that patients’ diagnoses should be taken into consideration when evaluating the self-generated coping strategies they use to deal with delusions. Previous studies have demonstrated that symptomatic coping is the most used strategy in schizophrenic patients [6, 17, 32, 33]. This type of coping strategy is also associated with less control over psychotic symptoms [33]. Bak et al. [32] demonstrated that the use of symptomatic coping distinguishes psychotic patients with the need for medical care from those without this need. Moreover, patients with schizophrenia are reported to have less supportive social networks, more problemRückl/Gentner/Büche/Backenstrass/ Barthel/Vedder/Bürgy/Kronmüller
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a Schizophrenia
Schizophrenia spectrum patients (n = 30)
Table 2. Comparisons between the groups in terms of distress associated with the delusional belief, control over the belief, and coping
Distress Control Coping Resource-oriented coping Medical care Distraction Cognitive coping Depressive coping Symptomatic behavior CRI CII CI
Affective disorder patients (n = 29)
mean
mean
SD
F(2,58)
p
SD
2.40 0.66
1.22 0.99
3.41a 0.48
0.73 0.63
14.83 0.71
0.003 0.40
6.90 4.90b 5.23 3.16 4.36 1.76b 14.36 2.26 31.16
4.48 5.39 3.56 2.79 3.26 1.22 6.03 0.48 11.81
8.72 2.10 4.89 3.03 7.44a 1.10 14.06 2.17 30.30
4.56 2.58 3.58 2.62 3.11 1.37 4.09 0.69 12.23
2.40 6.39 0.13 0.04 13.76 3.85 0.05 0.32 0.08
0.12 0.01 0.71 0.85 0.005 0.05 0.82 0.57 0.78
disorder > schizophrenia. b Schizophrenia > affective disorder.
Table 3. Spearman’s correlations between coping factors and di-
Table 4. Spearman’s correlations between coping factors and di-
mensions of delusion in the schizophrenia spectrum group (n = 30)
mensions of delusion in the affective disorders group (n = 29)
Action-oriented Cognitive Emotional dimension dimension dimension Resource-oriented Medical care Distraction Cognitive coping Depressive coping Symptomatic coping CRI CII
–0.13 –0.26 0.11 –0.44* 0.13 0.39 –0.12 –0.10
–0.39* –0.19 –0.32 –0.58** –0.28 0.26 –0.43* –0.20
0.38* –0.14 0.17 –0.01 0.56** –0.26 0.21 0.02
* p < 0.05, ** p < 0.01.
Action-oriented Cognitive Emotional dimension dimension dimension Resource-oriented Medical care Distraction Cognitive coping Depressive coping Symptomatic coping CRI CII
–0.38* –0.24 –0.18 –0.48** 0.04 0.15 –0.11 –0.43*
–0.05 –0.18 0.22 –0.11 –0.11 0.07 0.13 –0.24
–0.22 –0.13 0.07 –0.19 0.07 –0.14 0.13 –0.32
* p < 0.05, ** p < 0.01.
solving deficits [34], and impaired cognition [35], which can also contribute to a greater need for medical care. In the sample of patients with affective disorders, most (97%) had experienced a severe depressive episode with psychotic symptoms. Studies have demonstrated that patients with milder depressive episodes use more active problem-focused coping, whereas patients with severe depressive episodes use more avoidance strategies and emotional discharge to deal with stressors [36–38]. In the current study, we specifically examined the different coping strategies that patients used to deal with delusions and
found that patients with affective disorders used more depressive coping, which included strategies such as social withdrawal, isolation, and resignation, than patients with schizophrenia. Associations between the dimensions of delusions and coping factors were evident for the two groups of patients. For the sample of patients with schizophrenia spectrum disorders, the 3 dimensions of delusion (i.e. action-oriented, cognitive, and emotional) correlated significantly with the coping factors, whereas, for the sample of patients with affective disorder, only the action-oriented dimension showed significant correlations.
Delusions in Schizophrenia and Affective Disorder with Psychotic Symptoms
Psychopathology 2015;48:11–17 DOI: 10.1159/000363144
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a Affective
Schizophrenia spectrum patients (n = 30)
Investigation of the relationships between the different dimensions of delusion and coping can guide coping enhancement therapies to improve cognitive therapy interventions for patients with persistent symptoms. In addition to enhancing coping strategies, the action-oriented, cognitive, and emotional aspects of the delusional belief should be addressed as these aspects can influence the way patients deal with their symptoms [39]. For example, patients whose delusions are associated with great distress used more depressive coping, which can be considered a noneffective coping strategy. Approaching the emotional dimension of the delusion, that is, the emotions that are triggered by the beliefs, can change patients’ appraisal of the situation and, consequently, their coping behavior. Yusupoff and Tarrier [10] proposed that the patient’s emotional reactions to the symptoms’ cognitive, physiological, behavioral, and affective components are what define the symptom and create the conditions for maintenance. The Coping Strategy Enhancement (CSE) approach emphasizes identification of the determinants of a symptom, training of effective coping skills, and extension of the established coping methods with patients. A number of studies have shown that CSE can be effective in the treatment of patients with schizophrenia with residual psychotic symptoms [8] and hallucinations [9]. In conclusion, patients with schizophrenia spectrum disorders and those with affective disorder with psychotic symptoms cope differently with delusions. The patients
in the schizophrenia spectrum disorder group were more likely to use medical care and symptomatic coping, whereas patients with affective disorders were more likely to use depressive coping. In the schizophrenia group, action-oriented, cognitive, and emotional aspects of the delusions were related to coping, whereas, in the affective disorder group, only action-oriented coping was related to coping. These results suggest that both the enhancement of coping strategies and the different dimensions of delusion should be evaluated in patients. The present study has limitations. The sample was small and only in-patients with acute and severe symptoms were examined. These types of symptoms are usually associated with deficits in adaptive coping [40]. The group of patients with schizophrenia spectrum disorders included patients with schizophrenia and schizoaffective disorder. Although these two diagnoses share common symptoms, patients with schizoaffective disorders also have mood symptoms, which might influence their coping styles. This study was cross-sectional; given that coping and delusions are constantly changing phenomena, future longitudinal studies to evaluate changes in coping and delusions over time in both in- and out-patient populations would be of great value. Moreover, coping is a very complex phenomenon that is influenced by factors such the social environment, personality, cognition, diagnosis, and symptoms. These findings are preliminary and further research should be conducted to address coping with delusions.
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8 Tarrier N, Sharpe L, Beckett R, Harwood S, Baker A, Yusopoff L: A trial of two cognitive behavioural methods of treating drug-resistant residual psychotic symptoms in schizophrenic patients. Soc Psychiatry Psychiatr Epidemiol 1993;28:5–10. 9 Wiersma D, Jenner JA, van de Willige G, Spakman M, Nienhuis FJ: Cognitive behaviour therapy with coping training for persistent auditory hallucinations in schizophrenia: a naturalistic follow-up study of the durability of effects. Acta Psychiatr Scand 2001; 103: 393–399. 10 Yusupoff L, Tarrier N: Coping strategy enhancement for persistent hallucinations and delusions; in Haddock G, Slader, PD (eds): Cognitive-Behavioural Interventions with Psychotic Disorders. London, Routledge, 1996. 11 Jenner JA, van de Willige G, Wiersma D: Effectiveness of cognitive therapy with coping training for persistent auditory hallucinations a retrospective study of attenders of a psychiatric out-patient department. Acta Psychiatr Scand 1998;98:384–389.
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Received: December 12, 2012 Accepted after revision: April 18, 2014 Published online: September 9, 2014
Coping with Delusions in Schizophrenia and Affective Disorder with Psychotic Symptoms: The Relationship between Coping Strategies and Dimensions of Delusion Sarah Rückl a Nana Christina Gentner a Liesa Büche a Matthias Backenstrass a, c Andreas Barthel b Helmut Vedder b Martin Bürgy c Klaus-Thomas Kronmüller a, d
Department of Psychiatry, University of Heidelberg, Heidelberg, b Psychiatric Center Nordbaden, Wiesloch, Center of Mental Health, Bürgerhospital, Stuttgart, and d Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, LWL Clinic Gütersloh, Gütersloh, Germany c
Key Words Affective disorder · Coping · Delusion · Schizophrenia
Abstract Background: Self-generated coping strategies and the enhancement of coping strategies are effective in the treatment of psychotic symptoms. Evaluating these strategies can be of clinical interest to develop better coping enhancement therapies. Cognitive models consider delusions as multidimensional phenomena. Using a psychometric approach, the relationship between coping and the dimensions of delusion were examined. Methods: Thirty schizophrenia spectrum patients with delusions and 29 patients with affective disorder with psychotic symptoms were interviewed using the Heidelberg Coping Scales for Delusions and the Heidelberg Profile of Delusional Experience. Analyses of variance were conducted to investigate differences between the groups, and Spearman’s rank-based correlations were used to examine the correlations between coping factors and the dimensions of delusion. Results: Schizophrenia spectrum patients used more medical care and symptomatic coping, whereas patients with affective disorder en-
© 2014 S. Karger AG, Basel 0254–4962/14/0481–0011$39.50/0 E-Mail [email protected] www.karger.com/psp
gaged in more depressive coping. In the schizophrenia spectrum sample, the action-oriented, the cognitive, and the emotional dimensions of delusion were related to coping factors. In patients with affective disorder, only the actionoriented dimension was related to coping factors. Conclusion: Patients with schizophrenia and affective disorder cope differently with delusions. The dimensions of delusion are related to coping and should be regarded when using cognitive therapy approaches to enhance coping strategies. © 2014 S. Karger AG, Basel
Introduction
Previous research has demonstrated that both selfgenerated coping strategies [1–6] and cognitive-behavioral interventions that enhance coping strategies [7–11] are effective in the treatment of psychotic symptoms, such as delusions and hallucinations [10]. Given that over half of patients with schizophrenia have persistent or recurring delusions despite antipsychotic treatment [12, 13], examining how patients cope with delusions is of great importance. Understanding these coping strategies Sarah Rückl Department of Psychiatry University of Heidelberg Vossstrasse 4, DE–69115 Heidelberg (Germany) E-Mail sarah.rueckl @ med.uni-heidelberg.de
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a
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Psychopathology 2015;48:11–17 DOI: 10.1159/000363144
corporated in a psychometric approach to examine the relationships between coping and the action-oriented, cognitive, and emotional dimensions of delusion. Methods Participants Thirty patients with schizophrenia spectrum disorders experiencing delusions and 29 patients with an affective disorder with psychotic symptoms in the form of delusions participated in this study. All of the participants were receiving in-patient treatment at the Department of Psychiatry of the University of Heidelberg, the Psychiatric Center Nordbaden in Wiesloch, or the Center of Mental Health in Stuttgart. Patient diagnoses were determined through a structured clinical interview [26]. Exclusion criteria included severe medical conditions, neurological disorders, alcohol and drug dependency, and poor German language ability. This study was approved by the local ethics committee and was conducted in accordance with the ethical standards established by the Declaration of Helsinki [27]. The sample’s demographic characteristics are described in Results. Procedure The first step in this study was to contact the psychiatrist in charge to request consent for interviewing target patients. On first contact, an experimenter asked patients if they would like to participate in this study. Verbal and written information about the study was provided to each patient. Voluntary participation and anonymity were emphasized, and patients were informed that their participation would not influence the psychiatric and psychological treatment that they were receiving. After agreeing to participate in this study, patients were required to sign a written consent form. Data collection occurred within the context of a 45min interview with trained clinical psychologists or psychiatrists who had clinical experience. After a patient’s main delusional belief had been identified, the patient was informed that the interview would be about this specific delusional belief. Subsequently, the interviewer completed the Heidelberg Profile of Delusional Experience (unpubl. data). Then, patients were asked about the degree of distress that they experience with their delusional belief, and how much control they had over it. As lists of previously selected strategies can have the disadvantage of concealing strategies that were used successfully, patients were first encouraged to name all of the strategies that they used to manage their beliefs. This procedure assures an accurate assessment of the patient’s own experience with a symptom [2]. The answers were then divided and allocated into different categories; for example, if a patient said he isolates himself and avoids other people, this answer was classified as ‘social withdrawal’. It was also inquired as to how often each strategy was used. Then, patients were asked about the 33 predefined items of the Heidelberg Coping Scales for Delusions (HCSD). Finally, patients were asked to report their 3 most effective coping strategies. Instruments Coping strategies were assessed using the HCSD [28], which is an established instrument consisting of 33 coping strategies rated on a 5-point Likert scale ranging from ‘not at all’ to ‘very much.’
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in schizophrenia and affective disorder with psychotic symptoms can enhance therapeutic approaches to coping for patients who experience stress associated with delusions [14]. Yusupoff and Tarrier [10, p. 86] defined coping as ‘the active self-generation of cognitive and behavioral procedures either to impact the symptom directly or to minimize the resultant distress’. Lange [3] and Falloon and Talbot [4] published the first empirical studies on selfgenerated coping strategies in schizophrenia. The advantage of studying self-generated coping strategies is that patients are familiar with these strategies as they do not fall outside of the patients’ set of beliefs. These strategies allow patients to make sense of their own reality [15]. Lange [3] described the different coping behaviors of schizophrenic patients for managing the symptoms of schizophrenia, whereas Falloon and Talbot [4] focused on coping with hallucinations in schizophrenia. Both studies demonstrated that schizophrenic patients develop coping strategies to master their symptoms. This approach influenced future studies on coping, which have addressed questions regarding how patients cope with their disorders [2, 6, 14, 16–18], the prodromal phase [19], and their specific symptoms, including negative symptoms [20] and hallucinations [4, 21]. The results of these studies have indicated that patients with psychosis are actively involved in trying to manage their symptoms [2, 5, 6, 14, 16]. The use of several strategies has been associated with coping effectiveness [4, 5, 20]. Previous studies have reported that patients with schizophrenia apply cognitive strategies to cope with delusions and hallucinations [6, 16, 18], whereas behavioral strategies are used to deal with other symptoms, such as anxiety, depression, motor retardation, and thought disorders [6]. In spite of the amount of research examining coping, there is a lack of research focusing on coping with delusions. There is a definite need for studies comparing patients with schizophrenia and those with affective disorders with psychotic symptoms in the form of delusions. One study by van den Bosch and Rombouts [22] reported no differences between schizophrenic patients and patients with depression with regard to coping with problems and unpleasant situations. The aim of the present study was to compare the coping strategies used to deal with delusions in patients with schizophrenia and patients with affective disorder with psychotic symptoms. Recent cognitive models of delusions consider delusions to be multidimensional phenomena with cognitive, emotional, and action-oriented dimensions [23–25]. In the present study, cognitive models were in-
t tests were used to control for family-wise error. Associations were examined through Spearman’s rank-based correlations. p < 0.05 was considered statistically significant. All analyses were performed using SAS 9.12 (SAS Institute Inc., Cary, N.C., USA).
The HCSD also assesses the degree of distress caused by the delusional belief, the level of control over the delusional belief, and the 3 most effective strategies used to cope with delusions. Two coping indices were calculated to determine how many coping strategies the patients used and how often they used these strategies. The Coping Repertoire Index (CRI) calculates how many strategies the patients use, ranging from 0 (no strategy is used) to 33 (all of the strategies are used). The Coping Intensity Index (CII) is the sum of all of the ratings from all of the strategies (coping intensity; CI) divided by the number of strategies used by the patients. The factorstructure of the HCSD was examined using a principal component analysis with a varimax rotation, which yielded the following 5 factors: (1) resource-oriented coping (items: positive reevaluation, self-valorization, enjoyment, prosocial behavior, positive emotions, self-encouragement, humor, and searching for a meaning); (2) medical care (items: medical help, psychotherapy, trusting the therapist, medication compliance, disease acceptance, and information seeking); (3) distraction (items: alcohol and drug use, mental distraction, sensory distraction, distraction with specific activities, and distraction with unspecific activities); (4) cognitive coping (items: minimization, dissimulation, ignoring, controlling feelings, selfverbalization), and (5) depressive coping (items: social withdrawal, negative emotions, and resigning). The item for symptomatic coping was considered as a separate factor. Symptomatic coping has been defined as behaviors that are used to relieve discomfort, yet they often result in an increased expression of disorder-related behaviors [6]. The subscales showed internal consistency values ranging from α = 0.59 (cognitive coping) to α = 0.83 (resource-oriented coping). The interrater reliability was calculated using intraclass correlation coefficients, and the items showed values between ICC = 0.66 (resigning) and ICC = 0.96 (psychotherapy). Delusional belief and its dimensions were assessed with the Heidelberg Profile of Delusional Experience (unpubl. data), which is an established rating instrument used to assess and diagnose delusional beliefs in psychiatric disorders. A delusional belief was identified and classified according to the Association for Methodology and Documentation in Psychiatry [29], and 18 items were to assess delusion formal criteria. The factor-structure of the HPDE was examined using a principal component analysis with a varimax rotation, which yielded 3 factors [30]. The first factor was the action-oriented dimension and included the items of behavioral impact, pervasiveness of belief, preoccupation, and disruption in life caused by beliefs. The second factor was the cognitive dimension and included the items of conviction, perceptions of others’ views of beliefs, attempts to disprove beliefs, and insight into the delusional belief. The third factor was the emotional dimension and included negative and positive emotions and the distress associated with the delusional belief. The action-oriented dimension showed an internal consistency value of α = 0.78, and both the cognitive and the emotional dimensions had internal consistency values of α = 0.80. The interrater reliability was calculated using intraclass correlation coefficients and the items showed values between ICC = 0.71 (pervasiveness) and ICC = 0.92 (conviction) [31].
Sample In the schizophrenia spectrum disorder group, 22 of 30 patients (73.3%) had a diagnosis of schizophrenia, and 8 patients (26.7%) were diagnosed with schizoaffective disorder. Eleven participants were male (36.7%), and 19 participants were female (63.3%). The average age of this patient group was 46.96 years (SD = 12.21). Most patients were single (60%), 40% were employed, and 50% had less than 10 years of secondary education. These patients had experienced an average of 6 (SD = 7.17) hospital psychiatric treatments. Patients in this group scored an average of 67.5 points (SD = 10.23) on the PANSS total score. The mean level of global functioning, as measured by the Global Assessment of Function (GAF) scale [30], was 27 (SD = 5.68). In the affective disorder group, 28 of 29 patients (96.6%) had unipolar depression and were diagnosed with a severe depressive episode with psychotic symptoms at the time of the investigation. One patient (3.4%) had a bipolar disorder and presented a severe depressive episode with psychotic symptoms. The mean age of the 11 male (38.0%) and 18 female (62.0%) participants with affective disorder was 47.24 years (SD = 12.88). Most patients in this group (65.5%) were married or lived in a partnership, 44.8% were employed, and 55.1% had more than 10 years of secondary education. The mean number of hospital psychiatric treatments was 2.86 (SD = 1.88). Patients with affective disorder scored an average of 67.80 points (SD = 11.95) on the PANSS total score. The level of global functioning in this group of patients averaged 30.96 on the GAF (SD = 11.05). Differences between the groups were examined with one-way ANOVA, and patients with schizophrenia spectrum disorder had a greater number of hospital psychiatric treatments compared to patients with affective disorder (table 1). There were no differences between the groups with regard to age, GAF scores, or PANSS total scores.
Statistical Analysis One-way analyses of variance (ANOVA) were conducted to identify differences between the patients with schizophrenia spectrum disorders experiencing delusions and the patients with affective disorder with psychotic symptoms in the form of delusions. Bonferroni
Distress Associated with a Delusional Belief, Control over the Belief, and Coping Patients with affective disorders scored significantly higher on ratings of distress associated with a delusional
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Results
Table 1. Sociodemographic and psychopathological characteristics of the sample (n = 60)
Age, years Mean SD (range) Sex, n (%) Male Female Family situation, n (%) Single Married/partnership Divorced/widowed Secondary education, n (%) ≤10 years >10 years Employment situation, n (%) Employed Unemployed Retired Other GAF Mean SD (range) Psychiatric treatments Mean SD (range) PANSS total score Mean SD (range)
Affective disorder patients (n = 29)
F(2,58)
p
46.96 12.21 (22–66)
47.24 12.88 (23–71)
0.50
0.60
11 (36.7) 19 (63.3)
11 (38.0) 18 (62.0)
18 (60.0) 6 (20.0) 6 (20.0)
6 (20.7) 13 (44.8) 10 (34.5)
15 (50.0) 15 (50.0)
11 (37.9) 18 (62.1)
12 (40.0) 2 (6.6) 11 (36.7) 5 (16.7)
13 (44.8) 7 (24.1) 7 (24.1) 2 (7.0)
27.0 5.68 (15–50)
30.9 11.05 (18–68)
1.69
0.19
6.00a 7.17 (1–27)
2.86 1.88 (1–8)
5.16
0.02
67.50 10.23 (51–101)
67.80 11.95 (46–93)
0.01
0.92
> affective disorder.
belief and used more depressive coping to cope with delusion compared to the schizophrenia spectrum disorder patients, who used significantly more medical care and symptomatic coping (table 2). Relationships between the Dimensions of Delusion and Coping Factors For the schizophrenia spectrum disorder sample, the action-oriented dimension correlated significantly and negatively with cognitive coping. The cognitive dimension of delusion correlated significantly and negatively with resource-oriented coping, cognitive coping, and the CRI. Moreover, the emotional dimension of the delusional belief showed a significant positive correlation with depressive coping. For the sample of patients with affective disorder, the action-oriented dimension of the delusional belief correlated significantly and negatively with resource-oriented coping, cognitive coping, and the CII (tables 3, 4). 14
Psychopathology 2015;48:11–17 DOI: 10.1159/000363144
Discussion
Patients with schizophrenia used more medical care and symptomatic coping than patients with affective disorder, who were more likely to use depressive coping to deal with their delusional beliefs. These findings suggest that patients’ diagnoses should be taken into consideration when evaluating the self-generated coping strategies they use to deal with delusions. Previous studies have demonstrated that symptomatic coping is the most used strategy in schizophrenic patients [6, 17, 32, 33]. This type of coping strategy is also associated with less control over psychotic symptoms [33]. Bak et al. [32] demonstrated that the use of symptomatic coping distinguishes psychotic patients with the need for medical care from those without this need. Moreover, patients with schizophrenia are reported to have less supportive social networks, more problemRückl/Gentner/Büche/Backenstrass/ Barthel/Vedder/Bürgy/Kronmüller
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a Schizophrenia
Schizophrenia spectrum patients (n = 30)
Table 2. Comparisons between the groups in terms of distress associated with the delusional belief, control over the belief, and coping
Distress Control Coping Resource-oriented coping Medical care Distraction Cognitive coping Depressive coping Symptomatic behavior CRI CII CI
Affective disorder patients (n = 29)
mean
mean
SD
F(2,58)
p
SD
2.40 0.66
1.22 0.99
3.41a 0.48
0.73 0.63
14.83 0.71
0.003 0.40
6.90 4.90b 5.23 3.16 4.36 1.76b 14.36 2.26 31.16
4.48 5.39 3.56 2.79 3.26 1.22 6.03 0.48 11.81
8.72 2.10 4.89 3.03 7.44a 1.10 14.06 2.17 30.30
4.56 2.58 3.58 2.62 3.11 1.37 4.09 0.69 12.23
2.40 6.39 0.13 0.04 13.76 3.85 0.05 0.32 0.08
0.12 0.01 0.71 0.85 0.005 0.05 0.82 0.57 0.78
disorder > schizophrenia. b Schizophrenia > affective disorder.
Table 3. Spearman’s correlations between coping factors and di-
Table 4. Spearman’s correlations between coping factors and di-
mensions of delusion in the schizophrenia spectrum group (n = 30)
mensions of delusion in the affective disorders group (n = 29)
Action-oriented Cognitive Emotional dimension dimension dimension Resource-oriented Medical care Distraction Cognitive coping Depressive coping Symptomatic coping CRI CII
–0.13 –0.26 0.11 –0.44* 0.13 0.39 –0.12 –0.10
–0.39* –0.19 –0.32 –0.58** –0.28 0.26 –0.43* –0.20
0.38* –0.14 0.17 –0.01 0.56** –0.26 0.21 0.02
* p < 0.05, ** p < 0.01.
Action-oriented Cognitive Emotional dimension dimension dimension Resource-oriented Medical care Distraction Cognitive coping Depressive coping Symptomatic coping CRI CII
–0.38* –0.24 –0.18 –0.48** 0.04 0.15 –0.11 –0.43*
–0.05 –0.18 0.22 –0.11 –0.11 0.07 0.13 –0.24
–0.22 –0.13 0.07 –0.19 0.07 –0.14 0.13 –0.32
* p < 0.05, ** p < 0.01.
solving deficits [34], and impaired cognition [35], which can also contribute to a greater need for medical care. In the sample of patients with affective disorders, most (97%) had experienced a severe depressive episode with psychotic symptoms. Studies have demonstrated that patients with milder depressive episodes use more active problem-focused coping, whereas patients with severe depressive episodes use more avoidance strategies and emotional discharge to deal with stressors [36–38]. In the current study, we specifically examined the different coping strategies that patients used to deal with delusions and
found that patients with affective disorders used more depressive coping, which included strategies such as social withdrawal, isolation, and resignation, than patients with schizophrenia. Associations between the dimensions of delusions and coping factors were evident for the two groups of patients. For the sample of patients with schizophrenia spectrum disorders, the 3 dimensions of delusion (i.e. action-oriented, cognitive, and emotional) correlated significantly with the coping factors, whereas, for the sample of patients with affective disorder, only the action-oriented dimension showed significant correlations.
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a Affective
Schizophrenia spectrum patients (n = 30)
Investigation of the relationships between the different dimensions of delusion and coping can guide coping enhancement therapies to improve cognitive therapy interventions for patients with persistent symptoms. In addition to enhancing coping strategies, the action-oriented, cognitive, and emotional aspects of the delusional belief should be addressed as these aspects can influence the way patients deal with their symptoms [39]. For example, patients whose delusions are associated with great distress used more depressive coping, which can be considered a noneffective coping strategy. Approaching the emotional dimension of the delusion, that is, the emotions that are triggered by the beliefs, can change patients’ appraisal of the situation and, consequently, their coping behavior. Yusupoff and Tarrier [10] proposed that the patient’s emotional reactions to the symptoms’ cognitive, physiological, behavioral, and affective components are what define the symptom and create the conditions for maintenance. The Coping Strategy Enhancement (CSE) approach emphasizes identification of the determinants of a symptom, training of effective coping skills, and extension of the established coping methods with patients. A number of studies have shown that CSE can be effective in the treatment of patients with schizophrenia with residual psychotic symptoms [8] and hallucinations [9]. In conclusion, patients with schizophrenia spectrum disorders and those with affective disorder with psychotic symptoms cope differently with delusions. The patients
in the schizophrenia spectrum disorder group were more likely to use medical care and symptomatic coping, whereas patients with affective disorders were more likely to use depressive coping. In the schizophrenia group, action-oriented, cognitive, and emotional aspects of the delusions were related to coping, whereas, in the affective disorder group, only action-oriented coping was related to coping. These results suggest that both the enhancement of coping strategies and the different dimensions of delusion should be evaluated in patients. The present study has limitations. The sample was small and only in-patients with acute and severe symptoms were examined. These types of symptoms are usually associated with deficits in adaptive coping [40]. The group of patients with schizophrenia spectrum disorders included patients with schizophrenia and schizoaffective disorder. Although these two diagnoses share common symptoms, patients with schizoaffective disorders also have mood symptoms, which might influence their coping styles. This study was cross-sectional; given that coping and delusions are constantly changing phenomena, future longitudinal studies to evaluate changes in coping and delusions over time in both in- and out-patient populations would be of great value. Moreover, coping is a very complex phenomenon that is influenced by factors such the social environment, personality, cognition, diagnosis, and symptoms. These findings are preliminary and further research should be conducted to address coping with delusions.
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