Background
Environmental stressors are an important factor in the development of psychopathology [
1,
2]. Stress, however, has a subjective nature, which is reflected in the fact that an event becomes stressful only when it overwhelms an individual’s ability to cope with it [
3]. Coping refers to the process of managing the internal and external demands created by stressful events that are considered taxing or that exceed the individual’s resources [
4,
5]. A large body of evidence suggests that coping impacts on both physical and mental health [
5]. Coping can be described as existing along two dimensions, based on the approach or avoidance of the stressor [
5]. Examples of approach-oriented coping are active problem solving, or seeking social or professional support. Examples of avoidance-oriented coping include denying or ignoring the stressor, or displaying emotional responses to the stressor such as worrying or ruminating, or engaging in wishful thinking or self-blame. In general, approach-oriented coping is seen as adaptive coping, whereas avoidance-oriented coping is usually considered as non-adaptive coping [
5].
Poor coping is a well-established feature in the development of many psychiatric disorders [
1,
2], including the expression and development of psychosis [
6‐
8]. Studies have for example shown that non-adaptive coping is applied more often by individuals with chronic schizophrenia as well as by individuals who experience a first psychotic episode or relapse (see for review [
6]). More adaptive coping has been associated with better course and outcome; conversely, less adaptive coping has been associated with poorer course and outcome in psychosis [
5,
8]. Likewise, more non-adaptive coping has consistently been associated with poorer course and outcome in terms of symptom remission and general functioning [
5,
6]. Thus, poor coping encompasses both a high use of non-adaptive coping as well as a low use of adaptive coping. Good coping, conversely, encompasses a high use of adaptive coping and a low use of non-adaptive coping.
Recent research has shown that psychotic symptoms are prevalent in the population and commonly occur outside the range of a psychotic disorder [
9]. Meta-analyses of community studies have demonstrated a median prevalence of psychotic symptoms of 5% in adults [
9] and higher prevalences in children and adolescents, with a median population prevalence of 17% in 9-12 year olds and 7.5% in 13-18 year olds [
10]. Furthermore, these psychotic symptoms have been suggested to be a marker of psychopathological severity in people with psychiatric disorders [
11]. In both community and clinical samples of young people with non-psychotic psychiatric disorders, the presence of psychotic symptoms has been shown to be a strong marker of risk for multimorbidity (i.e. the presence of multiple co-occurring disorders) [
11] and suicidal behavior [
12]. In terms of etiological loading, it has furthermore been shown that a range of risk factors for psychotic disorder (including substance use, trauma and urbanicity) are more common in individuals with depressive or anxiety disorders who also report psychotic symptoms, compared to individuals with depressive or anxiety disorders who do not report psychotic symptoms [
13]. With regard to treatment and treatment response, patients with major depressive disorder (MDD) who report clinical [
14] or subclinical [
15] psychotic symptoms have been shown to have poorer treatment outcomes than patients with MDD without psychotic symptoms.
The exact mechanisms leading to these poorer (clinical and functional) outcomes, however, remain unclear. One factor that may contribute to poor functional outcome in patients with psychotic symptoms is poor coping. For one, poor coping has been proposed to serve as a direct and strong connection between psychopathology and functioning in psychotic disorder [
16]. Recent work in adolescents showed that individuals reporting subclinical psychotic experiences demonstrated more use of poor coping styles [
17‐
20]. In a study of general population adolescents, Lin and colleagues [
20] showed that the use of adaptive coping styles was associated with a decrease in psychotic experiences over time, whereas the use of non-adaptive copings styles was associated with persistence of such experiences over time. In addition to poorer coping, individuals with persisting psychotic experiences reported lower levels of functioning over time. To our knowledge, however, there has been no research to date on the association between psychotic symptoms and coping in clinical populations with (non-psychotic) psychiatric disorders, i.e. in relation to psychotic expression in the context of other psychopathology. The aim of this paper was to investigate whether poor coping might be a partial explanation for poor functional outcomes in patients with psychotic symptoms. We therefore addressed the following questions:
(i)
In a clinical sample of adolescents with non-psychotic psychiatric disorders, do adolescents with additional psychotic symptoms differ in their coping styles from adolescents without additional psychotic symptoms? Specifically, do patients who report psychotic symptoms demonstrate poorer coping skills than patients who do not report psychotic symptoms?
(ii)
Does coping moderate the association between psychotic symptoms and functioning?
Discussion
The current study showed that, in a clinical sample of adolescents referred to mental health services, the presence of psychotic symptoms in adolescents with non-psychotic psychiatric disorders was associated with both lower levels of functioning and more use of avoidance-oriented coping styles compared to adolescents with psychiatric disorders without psychotic symptoms. Although no significant moderation effects were found, probably due to too small subgroups and thus limited statistical power, the stratified analyses (stratified for good or poor coping) suggested that individuals with psychotic symptoms only had lower levels of functioning if they used poor coping (i.e. less use of approach-oriented coping styles and more use of avoidance-oriented coping styles). The findings of the current paper suggest that psychotic symptoms, poor coping and poor functioning are associated, but they cannot give definitive conclusions on the question whether poor coping moderates the association between psychotic symptoms and poor functional outcomes.
The Adolescent Coping Scale was found to be best represented by two underlying factors in the current sample, reflecting approach-oriented (adaptive) and avoidance-oriented (non-adaptive) coping. In line with earlier work on coping [
2,
5], these factors were shown to be independent, though not mutually exclusive, dimensions of coping. This independence was supported by the facts that the two factors were not correlated. Also, both
less use of approach-oriented coping and
more use of avoidance-oriented coping were suggestively associated with lower levels of functioning in patients with psychotic symptoms. Literature on coping in mental health research usually focuses mostly on avoidance-oriented or other non-adaptive coping styles. The current study, however, underlines the importance of also including adaptive coping, such as approach-oriented coping, in relation to mental health research, as suggested by Roe and colleagues [
8] who stress the importance of resilience in the context of mental health.
As we hypothesized, and consistent with complementary research [
5,
6,
8], patients with psychotic symptoms applied more avoidance-oriented coping than patients without psychotic symptoms. However, no differences were found with regard to approach-oriented coping; this is somewhat surprising since earlier work in the context of psychosis has shown that more adaptive coping is associated with better outcome [
8]. Patients with psychiatric disorders and psychotic symptoms did, however, report less use of approach-oriented coping, i.e. the (small) difference was in the expected direction, although non-significant.
Patients with psychiatric disorders and psychotic symptoms were rated with lower levels of functioning compared to patients with psychiatric disorders but without psychotic symptoms. Level of daily functioning is an important outcome in psychopathological research in addition to clinical outcome, especially from the point of view of the patient and their social context, clinicians and society [
27], and provides important information regarding an individual’s situation that is not per definition the same as or dependent on clinical diagnosis [
28,
29]. Thus, the current study underlines the importance of functioning as an outcome of interest in the context of psychotic symptoms, especially regarding possible avenues for intervention involving, for example, coping.
There are several possible explanations for the finding that adolescents with psychiatric disorders and additional psychotic symptoms report poorer functioning. It has been suggested that psychotic symptoms can be seen as an “index of severity” of psychopathology [
11]. Thus, individuals with psychotic symptoms may be more ill: individuals with psychiatric disorders who report psychotic symptoms simply have more symptoms of psychopathology than individuals with psychiatric disorders who do not report psychotic symptoms. To make sure that it is not the more severe psychopathological loading that explains the association between psychotic symptoms and functioning, we ran a post-hoc analysis in which presence of psychotic symptoms predicts functioning, while controlling for number of mental disorders present (as an index of psychopathological severity). After controlling for this, the effect of psychotic symptoms diminished somewhat but remained significant, showing that the effect of psychotic symptoms on functioning can be partly, but not wholly, explained by severity of illness (data not shown). Earlier work has also shown that common mental disorders with and without additional psychotic symptoms differed quantitatively by indicators of severity, course, onset, and environmental and familial risks, indicating that the co-presence of psychotic symptoms in non-psychotic psychiatric disorders is a common and functionally and etiologically highly relevant feature [
13]. Another explanation may be that individuals with additional psychotic symptoms represent a subgroup of adolescents in which psychotic symptoms are a relatively late expression of a developmental pathway that has started earlier in life. It has been suggested that whereas psychotic symptoms may arise in relatively later stages of psychopathological development, other issues such as cognitive impairments and poor social functioning may be present already in relatively early phases [
30]. Since these domains have been shown to be predictive of later functioning [
28,
31,
32], it may be that the individuals with psychiatric disorders with additional psychotic symptoms represent a subgroup of adolescents in which psychotic symptoms are an expression of such impairments.
Individuals with psychiatric disorders and additional psychotic symptoms reported both poorer coping and poorer functional outcome. This, in combination with the suggestive moderation effect of coping, suggests that individuals with psychotic symptoms may be less able to handle stressful situations and that this may affect their functioning in daily life. This is especially problematic since many studies have demonstrated strong associations between stress and/or trauma and psychotic development. These associations can be bidirectional. A large body of literature has shown that trauma can lead to psychotic development [
33,
34]. Vice versa, many studies have reported that stressful situations such as trauma [
34‐
36] and stressful life events [
37,
38] are more prevalent in individuals with psychotic symptoms and that stressful events often precede exacerbation of psychotic symptomatology [
38]. In fact, exposure to early adversities has been shown to sensitize an individual to pathogenic effects of later stressful life events in the context of psychosis [
39]. However, other studies have reported
fewer stressful life events in individuals with recent-onset schizophrenia [
40] and
fewer daily hassles in individuals at Ultra High Risk (UHR) for psychosis [
41], although these individuals did perceive the adverse events that they encountered as less controllable, less well handled and more distressing. A study by Docherty and colleagues [
37] furthermore showed that life events only lead to increases in symptom level in those patients who were most emotionally reactive to stress. Thus, it seems that a heightened sensitivity to stress may be the driving force in the pathogenic effect of environmental stress. This is in line with a large body of literature that has shown that individuals who are liable to psychosis are thought to be more sensitive to stress [
42]: patients with psychotic disorder as well as their healthy siblings [
43,
44], individuals considered at UHR for psychosis [
41], individuals with schizotypal personality disorder [
38] and individuals from the general population at heightened psychometric risk for psychosis [
45] all have been shown to be more reactive to stressful events.
Limitations
The findings of the current study should be interpreted in light of its strengths and limitations. Important strengths include the thorough assessment of psychiatric disorders, using a reliable, valid and widely used diagnostic interview conducted by highly trained professionals, the relatively large sample size for an in-depth interview study, and the clinical case-clinical control design. Also, the study focused not only on non-adaptive coping, as is the case with most research on coping, but also incorporated adaptive coping. In this way, it underlined the relative nature of coping, by showing that it is not so much the yes/no application of certain coping styles, but the degree to which one applies good or poor coping. Inevitably, the use of clinical in-depth interviews limits the use of extensive samples; as a result, the subgroup analyses involved smaller groups and, because of this, confidence intervals are wide in some cases. This limited statistical power may well explain why no significant moderation effects were found and replication of the study is therefore warranted. Another limitation is that since the analyses pertained to cross-sectional data, no conclusions regarding causality or directionality of the effects can be drawn. Use of illicit drugs that may be associated with the presence of psychotic symptoms was not taken into account in the current paper. Last, since only those patients were included who could be offered clinical service within 4 weeks of referral, the current sample may have relatively high levels of psychopathology. However, this ‘enrichment’ for psychopathological severity enabled us to test the association between the psychotic symptoms and functional outcome with maximal statistical power. Future research may address the development of coping and its moderating role between psychotic symptoms and functional outcome over time, ideally in the context of a larger intervention study.
Clinical implications
We have demonstrated that individuals with psychotic symptoms have poorer coping skills, which may make them less capable of managing these stressors in a healthy and effective way. Thus, stress seems to be, at least partly, in the eye of the beholder; this has important clinical implications with regard to our current findings, as our results suggestively show that having both psychotic symptoms and poorer coping leads to poorer functioning. Intervention strategies aimed at improving coping skills could offer important possibilities for attenuating this association, and thus potentially improving functional outcome. Coping has been shown to be modifiable through stress management [
5] and, more specifically in the context of psychosis, psychosocial interventions such as cognitive behavioral therapy (CBT) have shown potential in modifying coping in individuals with psychotic symptoms [
46‐
48]. When looking more in-depth at the specific coping items of the ACS, it can be seen that the items loading highest on the avoidance-oriented coping factor were ‘not coping’, ‘self-blame’, ‘wishful thinking’ and ‘worry’. The finding that avoidance-oriented coping is strongly expressed through these particular types of coping styles suggests that such feelings, cognitions and actions may deserve extra attention when offering clinical help. Similarly, items that loaded the highest on the approach-oriented coping factor were ‘seek relaxing diversions’, ‘focus on the positive’ and ‘physical recreation’. Therefore, such measures are not merely common sense advice, but represent strong expressions of approach-oriented coping and thus, their importance should be underlined when discussing potential improvements regarding coping. Encouraging patients to apply these easy-to-use strategies may form an accessible and easy route for better coping and, in turn, better functioning.
When addressing the concept of coping for assessment, intervention or research purposes, it should be kept in mind that coping is a very dynamic concept. Not only may coping styles and skills change dramatically during adolescence [
20,
49], coping styles and skills have also been shown to change and develop in the course of disease development and recovery [
8]. Furthermore, coping is assumed to show large individual differences based on factors such as personality, individual history and social context [
2,
50]. However, this dynamic nature is, in fact, advantageous in that it suggests that individuals can actively influence its development; this in turn may enhance feelings of control and empowerment that are vital for healthy recovery in individuals with psychosis [
8,
51].
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
JW performed the analyses and wrote the manuscript. ND participated in the design and coordination of the study and helped to draft the manuscript. IK contributed to the analyses and writing of the manuscript. AM and AK participated in the coordination and data collection of the study and drafting of the manuscript. MH helped with the drafting of the manuscript. CF and MC conceived of the study, participated in its design and coordination and helped to draft the manuscript. All authors read and approved the final manuscript.