Coping patterns as a valid presentation of the diversity of coping responses in schizophrenia patients

Psychiatry Research 144 (2006) 139 – 152 www.elsevier.com/locate/psychres

Coping patterns as a valid presentation of the diversity of coping responses in schizophrenia patients Michael S. Ritsner a,b,*, Anatoly Gibel a, Alexander M. Ponizovsky c, Evgeny Shinkarenko a, Yael Ratner a, Rena Kurs d a

Sha’ar Menashe Mental Health Center, Hadera, Israel Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel c Mental Health Services, Ministry of Health, Jerusalem, Israel d Lev-hasharon Mental Health Center, Netanya, Israel

b

Received 25 May 2005; received in revised form 23 September 2005; accepted 23 September 2005

Abstract This study aimed to identify coping patterns used by schizophrenia inpatients in comparison with those used by healthy individuals, and to explore their association with selected clinical and psychosocial variables. The Coping Inventory for Stressful Situations (CISS) was used to assess coping strategies among 237 inpatients who met DSM-IV criteria for schizophrenia and 175 healthy individuals. Severity of psychopathology and distress, insight into illness, feelings of selfefficacy and self-esteem (self-construct variables), social support, and quality of life were also examined. Factor analysis, analysis of covariance and correlations were used to examine the relationships between the parameters of interest. Using dimensional measures, we found that emotion-oriented coping style and emotional distress were significantly higher in the schizophrenia group, whereas the task-oriented coping style, self-efficacy, perceived social support and satisfaction with quality of life were lower compared with controls. When eight CISS coping patterns were defined, the results revealed that patients used emotion coping patterns 5.5 times more frequently, and task and task-avoidance coping patterns significantly less often than healthy subjects. Coping patterns have different associations with current levels of dysphoric mood and emotional distress, self-construct variables, and satisfaction with quality of life. Thus, the identified coping patterns may be an additional useful presentation of the diversity of coping strategies used by schizophrenia patients. Coping patterns may be considered an important source of knowledge for patients who struggle with the illness and for mental health professionals who work with schizophrenia patients. D 2005 Elsevier Ireland Ltd. All rights reserved. Keywords: Schizophrenia; Psychoses; Coping strategy; Stress

* Corresponding author. Mobile Post Hefer 38814, Sha’ar Menashe Mental Health Center, Hadera, Israel. Tel.: +972 4 6278750; fax: +972 4 6278045. E-mail address: [email protected] (M.S. Ritsner). 0165-1781/$ - see front matter D 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.psychres.2005.09.017

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1. Introduction Coping with stressful situations and adverse life events including mental disorders is an important personality resource and a measure of one’s adaptability. According to the cognitive-transactional theory of stress (Lazarus and Folkman, 1984), coping has been defined as one’s cognitive and behavioral effort to manage the internal and external demands of a person-environment transaction that is considered taxing or exceeding one’s resources. Research has indicated that schizophrenia patients are inflexible in their use of coping strategies or styles (Wilder-Willis et al., 2002), tend to use maladaptive or emotionoriented coping styles (Wiedl, 1992; Van Den Bosch et al., 1992; Higgins and Endler, 1995), and rely more on passive-avoidant strategies and less on active problem solving (Lysaker et al., 2004). In a recent study the authors found a significant relationship between coping strategies and both severity of symptoms and emotional distress (Ritsner et al., 2003). Avoidance-oriented coping strategies (distraction type) were found to be significantly and negatively correlated with paranoid symptom clusters. Experienced emotional distress, self-efficacy, and social support predicted coping strategies used by patients at the exacerbation and stabilization phases of schizophrenia, while severity of symptoms accounted for only 3.5% and 5.5% to 9% of the total variance of emotion- and task-oriented coping strategies, respectively (Strous et al., 2005). Another study found that maladaptive coping strategies and trait negative affectivity in schizophrenia were associated with individual emotional responses to psychosocial stressors (Horan and Blanchard, 2003). One of the major problems of coping research in psychiatry is the lack of clearly defined patterns of coping behavior, their prevalence and attribution among schizophrenia patients. Initial research in the field categorized various coping strategies into three main styles (task-, emotion-, and avoidance-oriented) (Endler and Parker, 1990; Parker and Endler, 1992). Task-oriented coping is used to actively solve an underlying problem, cognitively reconceptualize it and potentially minimize its adverse effects. Emotionoriented coping strategies are person-oriented, and

include emotional responses, e.g., self-preoccupation, self-blame, and fantasizing reactions. Avoidanceoriented coping involves both task and person orientations: one may avoid a stressful situation either by using social diversion, i.e., choosing to be with other people and seeking emotional support, or via self-distraction from stressful situation, e.g., bgiving up,Q denial, or engaging in a substitute task. Theoretically, each coping style reflects a distinct method or technique for negotiating challenging situations. However, in practice, different people may use similar coping strategies, while one specific person may have a whole repertoire of coping mechanisms and choose different strategies, depending on the circumstances (Folkman and Moskowitz, 2004). It is noteworthy, however, that there is no consensus among researchers regarding which coping strategy is most effective in reducing psychopathological symptoms and distress (Aldwin and Revenson, 1987; Carr, 1988; Thoits, 1995). Coping patterns may be associated with a variety of clinical, personal, and biological factors including cognitive impairment (Van Den Bosch and Rombouts, 1997; Lysaker et al., 2001; Wilder-Willis et al., 2002), personality traits (Uehara et al., 1999; McWilliams et al., 2003) and aging (Solano and Whitbourne, 2001). Also findings strengthening the hypothesis that temperament types in combination with elevated emotional distress, emotion-oriented coping and weak self-evaluation constructs, might represent a complex trait marker for underlying vulnerability to schizophrenia have been reported (Ritsner and Susser, 2004). The interactive model of schizophrenia suggests that bself-construct variables,Q i.e., self-efficacy and self-esteem as well as perceived social support, all serve as protective factors to facilitate coping with stressful situations. Although there is growing evidence of the important influence of these factors on outcomes in schizophrenia (Buchanan, 1995; Hultman et al., 1997; Lecomte et al., 1999; Ritsner, 2003), to date, no study has been conducted to explore how coping strategies may be associated with selfconstruct variables. The procedure to generate coping tools can be deductive (i.e., based on theoretical assumptions) or inductive (i.e., starting with observations). Both direc-

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tions are needed, but unfortunately, a firm balance between them is rarely found. In addition, the conceptual and technical quality of these steps is not always satisfactory, a point well made by Endler and Parker (1990) as they developed the Coping Inventory for Stressful Situations (CISS). We used the CISS to study changes in coping styles from exacerbation to stabilization phases of schizophrenia (Strous et al., 2005). Since there was a substantial correlation between different coping styles and clinical states, we defined coping patterns by combining various major coping styles (Ritsner and Ratner, 2004). Based on the tendencies of individual coping patterns to show change over time, four temporal coping types were distinguished: stable favorable and unfavorable, becoming favorable and unfavorable (Ritsner and Ratner, in press). Several important questions regarding the defined coping patterns used by schizophrenia patients remain unanswered. How many main coping strategies influence the coping abilities of schizophrenia patients and healthy subjects? Is there a substantial correlation between the three main coping strategies and the defined coping patterns? Do schizophrenia patients tend to use different coping patterns than healthy individuals? In addition, what are the clinical and psychosocial factors associated with coping patterns used by schizophrenia patients? This study aimed to investigate these crucial questions in a sample of schizophrenia inpatients. For this purpose, the following a priori hypotheses were examined: (1) Correlation coefficients between main coping strategy scores do not reach significant levels among patients with single and binary coping patterns. (2) Patients with schizophrenia substantially differ from healthy individuals in the rate of use of coping patterns. (3) Various coping patterns are differentially associated with clinical and psychosocial variables.

2. Methods 2.1. Participants The study sample was obtained from a database of the patient population participating in the bQuality of Life StudyQ at Sha’ar Menashe Mental Health Center,

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Hadera, Israel. A detailed description of the design, data collection, measures and findings of this study has been reported elsewhere (Ritsner et al., 2000, 2003). Briefly, the initial sample was systematically selected from the Sha’ar Menashe Mental Health Center case register according to the following inclusion criteria: (i) fulfillment of DSM-IV criteria (American Psychiatric Association, 1994) for schizophrenia, (ii) age 18–65, and (iii) provision of written informed consent for participation in the investigation. Patients with comorbid mental retardation, organic brain disease, any severe physical disorder, drug/ alcohol abuse, and low comprehension skills were excluded. All patients were physically healthy, with recent normal physical examinations, and had normal blood and urine laboratory test results. Patients not enrolled (because of mental retardation, organic brain disease, severe physical disorders, drug/alcohol abuse, or low comprehension skills) did not significantly differ from the study sample in terms of the sociodemographic and clinical characteristics studied (age, gender, diagnosis, age at onset, number of hospitalizations, and symptom severity). The Sha’ar Menashe Institutional Review Board and the Israel Ministry of Health approved the study. 2.2. Instruments 2.2.1. The Coping Inventory for Stressful Situations (CISS) Coping strategies, the dependent variable of the study, were evaluated with the CISS (Endler and Parker, 1990; Endler et al., 1993). It consists of 48 statements concerning ways in which people could react to various difficult, stressful, or upsetting situations. They comprise three 16-item orthogonal factors of task-oriented (T) coping (e.g., bThink about how I have solved similar problems,Q or bAnalyze the problem before reactingQ), emotion-oriented (E) coping (e.g., bTell myself it is not really happening to me,Q or bBlame myself for not knowing what to doQ), and avoidance-oriented (A) coping. In the present study, the patients were asked to indicate how often they currently used each of the 48 coping strategies on a 5-point scale ranging from 1 (bnot at allQ) to 5 (bvery muchQ). The CISS has demonstrated high reliability, convergent and concurrent validity (Ritsner et al., 2000; McWilliams et al., 2003). For the present

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sample, internal consistency of the CISS dimensions as measured by Cronbach’s coefficient a ranged from 0.86 to 0.95. 2.2.2. The Positive and Negative Syndrome Scale (PANSS) Clinical evaluation of patients was performed using the Positive and Negative Syndrome Scale (Kay et al., 1987). A five-factor model was used for analysis: positive, negative, activation, dysphoric mood and autistic preoccupations (White et al., 1997). 2.2.3. The Talbieh Brief Distress Inventory (TBDI) The TBDI is a 24-item self-report instrument used to measure emotional distress (Ritsner et al., 1995). Responses are scored on a 0- to 4-point scale, with higher scores indicating greater intensity of distress, and particular symptom severity. Subscale scores, which are the means for the items of the six subscales: obsessiveness, hostility, anxiety, and paranoid ideation (each with 3 items), sensitivity (4 items), and depression (7 items), and the TBDI index, which is the average of all 24 items, were computed. The TBDI is a brief, valid and reliable tool that provides quantitative information on the subjective distress from psychiatric symptoms. Internal consistency of the TBDI distress index was 0.92. Mean TBDI scores were significantly lower for healthy subjects than for schizophrenia patients (Ritsner et al., 2002b). 2.2.4. Self-construct and social support measures A number of self-construct variables were examined with the following standardized questionnaires. The General Self-Efficacy Scale is a 10-item standard abridged version of the GSES for evaluating a sense of personal competence in stressful situations (Jerusalem and Schwarzer, 1986). The Rosenberg SelfEsteem scale is a well-known 10-item self-report questionnaire for measuring self-esteem and selfregard (RSES; Rosenberg, 1965). The Multidimensional Scale of Perceived Social Support (MSPSS; Zimet et al., 1988) is a measurement of perceived social support defined as emotional support and the degree of satisfaction with social support from family, friends and significant others. For the present sample, self-report instruments demonstrated high reliability (Cronbach’s a): GSES (0.88), RSES (0.80), and MSPSS (0.91).

2.2.5. The Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) Quality of life (QOL) was assessed using the QLES-Q (Endicott et al., 1993). In this study, we used the general QOL index (an average score of the 60 items) ranging from 1 to 5 (Cronbach’s a = 0.95). The Q-LES-Q shows good validity, reliability, and internal consistency to evaluate satisfaction with life quality and to discriminate between the schizophrenia patients and non-patient controls (Ritsner et al., 2002a). 2.3. Data analysis Initially, the principal axis method of factor analysis with varimax-rotated factor matrix was performed to identify the factors associated with coping strategies. The eigenvalues are used to determine how many factors to retain. One rule-ofthumb is to retain those factors whose eigenvalues are N 1. Variables with an absolute loading greater than the amount set in the minimum loading option (N 0.4) were selected. Next, the general linear model of two-way analysis of covariance (ANCOVA) was applied to assess the main effect of the mental health state (1st factor: being schizophrenia patients or healthy subject) by sex (2nd factor) on coping styles controlling for age (years) and education (years). Effects of following additional covariates were also examined: distress, self-efficacy, self-esteem, social support, and quality of life. Pearson product-moment correlation coefficients were calculated to examine the relationships among different coping style measures. The relationships of coping patterns with demographic, clinical- and selfvariables were examined with analysis of variance (ANOVA). Comparison of continuous variables between groups of patients was done using two-tailed ttests or nonparametric Wilcoxon Rank Sum tests (z, when the data did not follow the normal probability distribution). Differences in proportions were examined with v 2-test or with Fisher’s exact test, if indicated. Odds ratios with 95% confidence intervals were also calculated. Cramer’s V test was used to measure the association between coping patterns and categorical variables independent of sample size (V ranges between 0 = no relationship and 1 = perfect relationship). A probability level b0.05 was chosen

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to indicate statistical significance. All analyses were performed using the Number Cruncher Statistical System (Hintze, 2001).

3. Results 3.1. Characteristics of the samples Table 1 presents characteristics of the samples. Of a total of 237 patients, 176 presented with paranoid type, 38 with residual type, 11 with disorganized type, 11 with undifferentiated type, and 1 with catatonic

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type. Overall, 128 (54%) patients received only first generation and 75 (31.6%) only second generation antipsychotics and 28 (11.8%) received both types (6 or 2.5% of the patients did not receive any antipsychotic agents). In addition, several patients received concomitant medications (36% benzodiazepines, 17% antidepressants, and 10% mood stabilizers) as clinically indicated. The nonpatient group included 175 healthy subjects from auxiliary hospital staff members excluding physicians (inclusion based on interview availability). They had no known psychiatric history and did not meet DSM-IV criteria for any mental disorder. The

Table 1 Sociodemographic and illness characteristics of 237 schizophrenia patients and 175 healthy subjects Characteristic

Patients Mean

Male, N (%) Marital status, N (%) Single Married Othera Age at examination, years Education, years Age of onsetb, years Illness duration, years Total number of hospitalizations Paranoid subtype of illness PANSS, total Negative Positive Activation Dysphoric mood Autistic preoccupation Emotional distress (TBDI) Self-efficacy (GSES) Self-esteem (RSES) Social support (MSPSS) Quality of life, general index (Q-LES-Q)

Healthy subjects S.D.

Mean

S.D.

188

(79.3%)

65

(37.1%)***,1

150 44 43 37.9 10.2 23.4 14.3 7.6 176 84.3 30.0 12.4 14.8 11.4 19.1 1.3 27.3 18.1 55.4 3.4

(63.3%) (18.6%) (18.1%) 9.9 2.8 7.8 9.4 4.6 (73.4%) 19.5 8.5 4.7 4.4 3.9 5.2 0.8 8.0 4.8 17.8 0.7

24 132 18 38.4 13.7

(13.8%)***,2 (75.9%) (10.3%) 10.0 2.1*** – – – – – – – – – – 0.4***,3 4.5***,3 4.9 12.6***,3 0.4***,3

Significance: *P b 0.5, **P b 0.01, ***P b 0.001. a Widowed or divorced. b As per age of initial mental health care referral. c PANSS: higher ratings indicate a severe psychopathology. d TBDI: scores range between 0 and 4; higher scores indicate a severe emotional distress. e GSES: scores range between 10 and 40; higher scores indicate a higher self-efficacy. f RSES: scores range between 10 and 40; higher ratings indicate a higher self-esteem. g MSPSS: scores range between 12 and 84; higher ratings indicate a higher perceived social support. h Q-LES-Q: scores range between 1 and 5; higher ratings indicate a higher satisfaction with life quality. 1 2 v -test = 75.5, df = 1, P b 0.001. 2 2 v -test = 139.1, df = 2, P b 0.001. 3 Wilcoxon Rank Sum test.

0.4 34.9 16.9 67.3 4.1

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Table 2 Factor analysis for CISS items among 237 schizophrenia patients CISS items

Factor loadings after varimax rotation Factor 1

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48.

0.5970 0.6717 0.2981 0.2907 0.2990 0.5533 0.0397 0.1562 0.2032 0.6497 0.1550 0.1485 0.0674 0.1427 0.5382 0.2384 0.2035 0.2256 0.0732 0.2244 0.6046 0.1673 0.2768 0.6210 0.0151 0.6806 0.6709 0.2800 0.2459 0.3083 0.0623 0.3746 0.1784 0.0738 0.1806 0.6895 0.2797 0.0131 0.6711 0.2079 0.7173 0.7297 0.6537 0.2315 0.0688 0.5206 0.7114 0.1763

Factor 2 0.0444 0.0094 0.1028 0.0429 0.4036 0.0563 0.5481 0.6093 0.2277 0.0042 0.2918 0.1584 0.6422 0.7589 0.1050 0.4709 0.6565 0.0919 0.6887 0.0727 0.1306 0.6971 0.1473 0.1684 0.5173 0.0021 0.1178 0.5121 0.0496 0.4483 0.0738 0.07169 0.4588 0.4407 0.1585 0.0106 0.0184 0.6307 0.0199 0.0765 0.1305 0.1116 0.1563 0.2611 0.4806 0.0515 0.0020 0.0277

Commonalities after varimax rotation Factor 3 0.2246 0.1540 0.4337 0.4249 0.0843 0.2658 0.1740 0.0904 0.4177 0.2219 0.4001 0.5770 0.0152 0.0277 0.1871 0.3060 0.0758 0.5935 0.1552 0.5569 0.1038 0.0094 0.5226 0.1609 0.0060 0.1503 0.1724 0.1884 0.5622 0.1315 0.4461 0.4936 0.3082 0.1897 0.4280 0.2273 0.5543 0.0217 0.2552 0.5712 0.3054 0.2356 0.2149 0.5559 0.1971 0.3528 0.2332 0.6076

Factor 1

Factor 2

Factor 3

0.3564 0.4512 0.1585 0.0845 0.0894 0.3062 0.0015 0.0244 0.0412 0.4221 0.0240 0.0220 0.0045 0.0203 0.2896 0.0568 0.0414 0.0509 0.0053 0.0503 0.3655 0.0280 0.0766 0.3857 0.0002 0.4632 0.4501 0.0601 0.0604 0.0950 0.0038 0.1403 0.1289 0.0245 0.1310 0.4754 0.0782 0.0001 0.4504 0.0432 0.5145 0.5325 0.4273 0.1304 0.0047 0.2711 0.5061 0.0311

0.0019 0.0001 0.0105 0.0018 0.2308 0.0031 0.3004 0.3713 0.0518 0.0000 0.0851 0.0250 0.4124 0.5760 0.0110 0.3734 0.4310 0.0084 0.4743 0.0052 0.0170 0.4859 0.0217 0.0283 0.2676 0.0000 0.0138 0.2695 0.0024 0.2010 0.0054 0.0051 0.3670 0.3161 0.0251 0.0001 0.0003 0.3977 0.0003 0.0058 0.0170 0.0124 0.0244 0.0682 0.1448 0.0026 0.0000 0.0007

0.0504 0.0237 0.2881 0.2805 0.0071 0.0707 0.0302 0.0081 0.2009 0.0492 0.1841 0.3329 0.0002 0.0007 0.0350 0.0936 0.0057 0.3522 0.0240 0.3101 0.0107 0.0001 0.3732 0.0258 0.0000 0.0226 0.0297 0.0355 0.3161 0.0172 0.1990 0.2549 0.0950 0.0359 0.2832 0.0516 0.3073 0.0004 0.0651 0.3262 0.0932 0.0555 0.0462 0.5565 0.0388 0.1244 0.0544 0.3691

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Table 3 Comparison of coping style scores between 237 schizophrenia patients and 175 healthy subjects CISS dimensions Patients M

Controls ANCOVA1 Emotional distress2 Self-efficacy3 Self-esteem4 Social support5 Quality of life6

S.E. M

S.E. F

P

F

Task coping 50.4 0.9 62.4 1.1 39.6 0.001 28.7 Emotion coping 43.6 0.8 36.0 1.0 19.2 0.001 0.08 Avoidance coping 47.2 0.9 48.2 1.1 0.3 0.61 0.01

P

F

P

F

P

F

P

F

P

0.001 0.78 0.99

6.7 12.5 6.2

0.01 0.001 0.013

71.0 36.8 0.8

0.001 0.001 0.14

35.7 23.4 1.8

0.001 0.001 0.64

14.4 8.9 4.6

0.001 0.003 0.003

Means and standard errors (S.E.) are shown. 1 Two-way ANCOVA: 1st factor — being schizophrenia patient or healthy subject (df = 1, 412); 2nd factor — sex (df = 1, 412) with controlling for age (years) and education (years). Additional covariates (scores): 2 The Talbieh Brief Distress Inventory, 3 The General Self-Efficacy Scale (patients: 49.5 F 0.9, controls: 45.2 F 1.0), 4 The Rosenberg Self-Esteem scale, 5 The Multidimensional Scale of Perceived Social Support, and 6 The Quality of Life Enjoyment and Satisfaction Questionnaire (patients: 49.1 F 0.9, controls: 45.4 F 1.0). Significance: *P b 0.05, **P b 0.01, ***P b 0.001.

healthy subjects were comparable to the schizophrenia patients with regard to mean age ( P N 0.05), but female, married, and more educated persons were overrepresented (all P b 0.001); and consequently, we examined the role of these covariates in data analysis. As depicted in Table 1, schizophrenia patients reported higher emotional distress, and lower selfefficacy, perceived social support and satisfaction with quality of life, than healthy subjects (all P b 0.001). 3.2. Coping styles To identify the main factors associated with the 48 items of the CISS, we performed an exploratory factor analysis on the correlation matrix of the observed 48 CISS items. Among schizophrenia patients three factors were identified on the highest eigenvalues: the first factor included task coping related items, the second was constructed using items related to emotion coping strategy, and the third factor comprised items presented in the avoidance coping style (Table 2). Eigenvalues were 9.15, 4.99, and 4.94 (7.67, 6.54 and 6.06 for healthy subjects), respectively. Correspondingly, these factors accounted for 346.9%, 25.6%, and 25.3% of the total variance among patients (for 36.6%, 31.2%, and 28.9% among healthy controls), respectively.

The mean scores of the three CISS coping dimensions of controls and schizophrenia patients were compared (Table 3). As can be seen, the emotion-oriented coping style was significantly higher in the schizophrenia group, whereas the task-oriented coping style was lower compared with controls. No significant difference between the groups was revealed for the avoidance-oriented coping style. ANCOVA indicated that between-group differences in emotion coping style scores appear to be associated with between-group differences in emotional distress, whereas between-group differences in avoidance coping style scores related to self-efficacy and quality of life. Self-esteem and social support scores did not associate with betweengroup differences in coping styles. Between-group differences in task-oriented coping style scores were unrelated to the covariates tested. 3.3. Coping patterns To increase accuracy, analysis of coping patterns as combinations of the three coping styles or dimensions were performed. In this study median scores obtained from the distributions of healthy subjects were used as cut-off points to split task-, emotion- and avoidanceoriented coping style scores into the two levels: high

Notes to Table 2: Means and standard errors (+ SE) are shown. 1 Two-way ANCOVA: 1st factor — being schizophrenia patient or healthy subject (df = 1, 412); 2nd factor — sex (df = 1, 412) with controlling for age (years) and education (years). Additional covariates (scores): 2The Talbieh Brief Distress Inventory; 3The General Self-Efficacy Scale (patients: 49.5 F 0.9, controls: 45.2 F 1.0). 4The Rosenberg Self-Esteem scale, 5The Multidimensional Scale of Perceived Social Support, and 6 The Quality of Life Enjoyment and Satisfaction Questionnaire (patients: 49.1 F 0.9, controls: 45.4 F 1.0).

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Table 4 Pearson correlation coefficients between coping style scores across coping patterns Coping patterns

Patients

Controls

N

rTE

All patients Task (T) Emotion (E) Avoidance (A) Task and Emotion (TE) Task and Avoidance (TA) Emotion and Avoidance (EA) Task, Emotion, Avoidance at high levels (h-TEA) Task, Emotion, Avoidance at low levels (l-TEA)

237 7 77 9 7 11 48 40 38

0.36*** 0.22 0.10 0.19 0.40 0.38 0.24 0.19 0.32

r TA

r EA

0.66*** 0.26 0.16 0.18 0.05 0.09 0.23 0.33* 0.45**

N

0.39*** 0.28 0.19 0.04 0.24 0.03 0.13 0.02 0.19

rTE

175 27 14 13 10 18 27 27 39

r TA

0.16* 0.10 0.25 0.05 0.42 0.09 0.10 0.41* 0.26

0.38*** 0.08 0.45 0.12 0.14 0.08 0.15 0.18 0.40*

r EA 0.46*** 0.25 0.18 0.53 0.11 0.11 0.33 0.32 0.39*

Significance: *P b 0.05, **P b 0.01, ***P b 0.001.

and low. Thus, the cut-off point scores on task-, emotion- and avoidance-oriented coping subscales were 64, 35 and 48, respectively. The scores higher than the median reflect the participant’s coping pattern that may include one, two or all three coping strategies. For example, the combination of high taskand high emotion-oriented coping with low avoidance-oriented coping is defined as a TE coping pattern. Using this method, apart from the pure coping styles (T, E, and A oriented), we identified the following pairs of coping patterns: task-emotion

(TE), task-avoidance (TA), and emotion-avoidance (EA) patterns. In addition, there were triplet combinations of all coping styles: task-emotion-avoidanceoriented (TEA) at two levels: higher and lower than median score (h-TEA and l-TEA, respectively). Pearson correlation coefficients on whole samples of participants and across coping patterns are presented in Table 4. As can be seen, three main coping styles were significantly and positively correlated on whole samples (r = 0.16–0.66, P b 0.05–b0.001), while these correlations did not reach significant

80

70

Mean scores

60

50

40

30

20 T

E

A

TE

TA

EA

h-TEA

l-TEA

Total

Coping patterns Task oriented coping

Emotion oriented coping

Avoidance oriented coping

Fig. 1. Mean score of task-, emotion- and avoidance-oriented coping strategies across coping patterns among 237 schizophrenia patients.

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Table 5 Frequency of coping patterns among 237 patients with schizophrenia and 175 non-patient controls Coping patterns

Task oriented (T) Emotion oriented (E) Avoidance oriented (A) Task and Emotion oriented (TE) Task and Avoidance oriented (TA) Emotion and Avoidance oriented (EA) Task, Emotion, Avoidance oriented at high levels (h-TEA) Task, Emotion, Avoidance oriented at low levels (l-TEA)

Schizophrenia

Healthy subjects

Fisher’s exact test

Odds ratio

N

%

N

%

P

(95% CI)

7 77 9 7 11 48 40 38

3.0 32.5 3.8 3.0 4.6 20.3 16.9 16.0

27 14 13 10 18 27 27 39

15.4 8.0 7.4 5.7 10.3 15.4 15.4 22.4

0.001 0.001 0.12 0.21 0.032 0.24 0.79 0.12

0.2 5.5 0.5 0.5 0.4 1.4 1.1 0.7

levels among patients with single and binary coping patterns. Correlation coefficients between coping strategy scores remained significant only among participants who used triplet coping patterns (hTEA, r = 0.33–0.45, P b 0.05–b0.01; and l-TEA, r = 0.39–0.41, P b 0.05). Mean scores of task-, emotion- and avoidance-oriented coping strategies were evaluated among patients across coping patterns as depicted in Fig. 1. As can be noted, patients with T and TE coping patterns showed higher scores on the task-oriented coping subscale. Patients who used A, TA, h-TEA and l-TEA patterns reported higher scores on task- and avoidance coping subscales, while

(0.40–0.008) (9.8–2.9) (1.2–0.2) (1.3–0.2) (0.9–0.2) (2.3–0.8) (1.9–0.6) (1.1–0.4)

patients with E and EA coping patterns scored similarly on the three CISS subscales. 3.4. Frequency of coping patterns Table 5 shows that the groups studied differed significantly in frequencies of the coping patterns (v 2 = 57.6, df = 7, P b 0.001). Specifically, the patients with schizophrenia used the E-oriented coping pattern 5.5 times more often than the non-patients ( P b 0.001). By contrast, patients used T and TA coping patterns less frequently than non-patients (odds ratio = 0.2–0.4). The patients and non-patients

5 Distress

4.5

Quality of life

4

Mean scores

3.5 ANOVA (df= 7,237) and TukeyKramer post-hoc test (P<0.05):

3 2.5

Distress: F=6.8, P<0.001 EA>TA, l-TEA; E>T, TA, l-TEA; h-TEA>TA, l-TEA. Quality of life: F=7.6, P<0.001 T>E, EA, l-TEA; TA>E, EA, l-TEA; A>E. h-TEA>E

2 1.5 1 0.5 0 T

E

A

TE

TA

EA

h-TEA

l-TEA

Coping patterns Fig. 2. Emotional distress and quality of life scores of 237 schizophrenia patients with various coping patterns.

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did not differ in the frequency of the use of A, TE, EA and coping triplets (TEA) at both high and low levels. 3.5. Factors associated with coping patterns We then analyzed the eight coping patters within the schizophrenia group for psychopathology and psychosocial factors. Using ANOVA, we found a significant association of coping patterns with dysphoric mood ( F = 5.1, df = 7, 237, P b 0.001; but not with other symptoms), emotional distress ( F = 6.8, df = 7, 237, P b 0.001), quality of life ( F = 7.6, df = 7, 237, P b 0.001), self-efficacy ( F = 13.5, df = 7, 237, P b 0.001), self-esteem ( F = 9.2, df = 7, 237, P b 0.001) and perceived social support ( F = 4.4, df = 7, 237, P b 0.001). Specifically, Tukey–Kramer post hoc comparisons showed that the E, EA, and low-TEA coping patterns were associated with more severity of dysphoric mood and emotional distress, poorer quality of life, and lower scores on self-efficacy, self-esteem and perceived social support (Figs. 2, 3). The coping patterns were not associated with gender (V = 0.17), marital status (V = 0.26), living arrangement (V = 0.29), employment status (V = 0.12), and treatment settings (V = 0.38, all P N 0.05). ANOVA also demonstrated no significant associations between

the coping patterns and patient’s age ( F = 0.27, df = 7, 237, P = 0.96), education years ( F = 1.5, df = 7, 237, P = 0.18), age at onset of illness ( F = 0.70, df = 7, 237, P = 0.68), illness duration ( F = 0.15, df = 7, 237, P = 0.99), and total number of psychiatric hospitalisations ( F = 0.81, df = 7, 237, P = 0.58).

4. Discussion The principal aim of this study was to define and explore the possible combinations of different coping styles among patients with schizophrenia in comparison with the non-patient subjects. The measurement of coping is complicated by dimensionality of coping strategies. Using various instruments, some reports come up with two or three, others with 8, 13, or even 28 coping scales, developed in either a rational or empirical manner (Amirkhan, 1990; Budd et al., 1998). There is agreement regarding some of the major factors, such as either problem focus and emotion focus, or vigilance and avoidance, or a combination of both sets (Folkman, and Moskowitz, 2004). Obviously, these are conceptually highly abstract whereas others are more proximal to the coping responses.

80 1. Self-efficacy 2. Self-esteem 3. Social support

70

ANOVA (df= 7,237) and Tukey-Kramer post-hoc test (P<0.05):

60

Mean score

50

3

40 30 1 20 2 10

Self-efficacy: F=13.5, P<0.001 T>E; TA>E, EA, l-TEA; h-TEA>E, EA, l-TEA. Self-esteem: F=9.2, P<0.001 T>E, EA, l-TEA, h-TEA; TA>E, EA, l-TEA, h-TEA; h-TEA>T, E, TA; A>E. Social support: F=4.4,

0 T

E

A

TE

TA

EA

h-TEA

l-TEA

Coping pattern Fig. 3. Self-constructs and social support among 237 schizophrenia patients with various coping patterns.

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The weakness of most of the measures lies in their unsatisfactory psychometric properties, unstable factor structures, and lack of cross-validation. These shortcomings have been overcome with the CISS, which was developed in an accurate and rigorous manner. Therefore, the first question addressed in this study was: How many factors (coping strategies) underlie coping abilities among schizophrenia patients and healthy subjects? We performed an exploratory factor analysis with 48 items of the CISS. The obtained factor structure of the CISS measure in this sample of schizophrenia patients appears to correspond to the three orthogonal factors (task-oriented, emotion-oriented, and avoidance-oriented) that were identified when the scale was developed (Endler and Parker, 1990; Parker and Endler, 1992). Recently, the psychometric properties of the CISS were evaluated in a large sample of outpatients with major depressive disorder (N = 298). The CISS scales demonstrated good reliability and support for their factorial validity was obtained (McWilliams et al., 2003). A serious problem, however, is that coping styles can be confounded. Indeed, we found significant correlations between all coping styles in both groups. In addition, the distinction between task- or problemfocused coping and emotion-focused coping is widely acknowledged, but many authors (Carver et al., 1989) felt that this was too simple. They believe that both coping functions have to be subdivided because there are a variety of distinct ways to solve problems or to regulate emotions. As stated in Section 3, an important finding of the study demonstrated that different CISS dimensions in fact coexisted as CISS patterns — coping style scores were significantly associated with one other. This finding supports the conclusion that different CISS dimensions may characterize the same individual. Therefore, we proceeded to define eight CISS coping patterns that may come from any combination of CISS dimensions. Theoretically, such an approach is based on the assumption that each subject may use more than one coping strategy to negotiate challenging situations. To test this assumption, a second question was addressed in this study: is there a substantial correlation between three main coping strategies and the defined coping patterns (hypothesis 1)? This study indicates

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that correlations between the three coping styles did not reach significant levels among patients with single (T, E, A) and binary (TA, TE, EA) coping patterns, but remained significant only among participants who used triplet coping patterns (h-TEA, l-TEA). Using dimensional measures, this study indicates that the emotion-oriented coping style and emotional distress were significantly higher in the schizophrenia group, whereas the task-oriented coping style, selfefficacy, perceived social support and satisfaction with quality of life were significantly lower compared with controls. In order to validate coping patterns, we compared their prevalence in the two samples. Findings supported the hypothesis that the number of strategies used by patients did substantially differ from that of healthy individuals in frequency of the use of distinct coping strategies and combined coping patterns (hypothesis 2). Specifically, the patients with schizophrenia were more likely (5.5 times) to use emotion-related coping pattern (5.5 times), and rarely used pure task-oriented and combined task-avoidance coping patterns relative to healthy subjects. These findings are consistent with Wiedl’s (1992) observations that schizophrenia patients who were highly stressed by their symptoms and impairments tended to use more emotional methods of coping than those who experienced lower levels of stress. Noteworthy, we found that similar proportions of patients with schizophrenia and healthy subjects reported the use of all three coping mechanisms as an inefficient way of coping with stress (low-TEA). These findings also strongly suggest that for schizophrenia patients, the borders between distinct coping strategies are less clearly delineated than for healthy people. The explanations could be an idiosyncratic perception of stressful context, including its controllability (Baum et al., 1983; Folkman et al., 1986), perplexing influence of psychopathology and personality dispositions (Carver and Scheier, 1994), and lack of social resources (Pierce et al., 1996) in schizophrenia patients. Alternatively, patients who simultaneously use all three strategies might be more desperate to attempt to use everything possible in the hope of finding something that can alleviate their condition. Again, without specifically assessing the situations or stressors encountered by the subjects, it is difficult to discern which coping combinations are adaptive or not.

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In view of the above findings, we addressed the central question raised in our study: Which clinical and psychosocial factors are associated with coping patterns used by schizophrenia patients? Findings from this study support the view (hypothesis 3) that persons diagnosed with schizophrenia use coping patterns significantly associated with current levels of dysphoric mood and emotional distress, selfconstruct variables, and satisfaction with quality of life. These findings are consistent with some studies that reported a relationship between the coping abilities of schizophrenia patients and psychosocial variables, such as quality of life (Ritsner et al., 2000; Bechdolf et al., 2003; Ritsner, 2003), self-efficacy (McDermott, 1995; Lecomte et al., 1999; Semple et al., 1999; Lysaker et al., 2001), and social support (Bengtsson-Tops, 2004). However, in the discussion on adaptive/nonadaptive coping responses, the relative nature of this opposition should be taken into consideration. Though task-oriented coping is considered more adaptive (Parker and Endler, 1992), at times other avoidant- or emotional-related strategies may be more adaptive depending on the situation. We know from Lazarus and Folkman (1984) that the cognitive appraisal of a situation guides the action, and that stressors or situations that cannot be changed or acted upon should trigger coping responses that are less active and more passive or internal. Research on coping in schizophrenia is important since there is evidence that the capacity to cope with emotional distress caused by distinct symptoms, impairments, and the illness as a whole substantially contributes to quality of life (QOL) outcomes. More specifically, emotion-oriented coping seems to mediate the relationship between QOL and the severity of activation, anxiety and depression symptom clusters, while avoidance-oriented coping (distraction type) mediates the association between QOL and paranoid symptoms (Ritsner et al., 2003). Task- and emotionoriented coping styles however do not moderate the relation between QOL and both positive and negative symptoms of schizophrenia (Rudnick, 2001). The limitations of our study are few and obvious. Since the comparison group included more female, married, and higher educated subjects than the patient group, these differences could account for the between-group differences in coping patterns. However, the finding that coping patterns are dissociated

from demographic variables precludes a demographic bias. Because data were received from inpatients, our findings may not necessarily generalize to less ill patients during the more stable outpatient phase. The effects of specific stressful life events and daily hassles were not tested.

5. Conclusions This study provides evidence for the validity of CISS coping patterns in patients with schizophrenia. This suggests that coping patterns may be considered an important source of knowledge for patients who struggle with the illness and for mental health professionals who work with schizophrenia patients. Given these results, coping patterns appear to be a useful tool for future studies of coping abilities of patients with various mental disorders, as well as for the effects of personal characteristics and inner resources underlying these coping strategies. It would also be interesting to test these findings in earlier phases of the illness. Further elaboration is necessary to identify subgroups of coping strategies that remain stable across individuals and situations.

Acknowledgements Authors’ contributions: MSR contributed to study design, and oversaw data collection. AG, ES, YR contributed to data collection. Data analysis was performed by MSR. Manuscript preparation was handled primarily by MSR and AMP, with contributions from AG, ES, YR, and RK; revised version was prepared by MRS and RK with contributions from AG, ES, YR, and AMP. All authors read and approved the final manuscript.

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