4. Discussion
This study assessed the role of coping style and self-esteem in the
context of four points of the schizophrenia continuum including HC, UHR,
FEP and ReSch and got some main findings. Firstly, the subscales of
coping strategies such as problem-solving, requesting assistance,
imagination and repression had significant differences between the four
groups. In contrast to the FEP and ReSch groups, post hoc analyses
showed that the UHR group had more positive coping strategies including
the use of problem solving and aid seeking, but more negative coping
strategies such as dreaming than the HC group. Three binary logic
regression models and ANCOVA analyses both supported this conclusion.
These findings showed that in comparison with HC group, UHR group used
more harmful coping mechanisms. This is in line with the similar
findings in previous studies.
Lee et al(Lee et al., 2011) found that the UHR population used more
emotion-focused coping styles than the HC population, and Masillo et al
(Masillo et al., 2012) also found that the UHR population used
maladaptive, avoidant coping styles more frequently than the HC
population. Individuals with UHR used avoidant coping styles such as
social withdrawal, habits or adaptation to illness, substance abuse or
alcohol abuse, among others. Phillips et al (Phillips et al., 2009) also
found that UHR group employed more emotional coping styles and less task
coping styles compared to HC group, though without discernible variation
within avoidant coping style implementation.
The current study also found that there was no discernible impairment
and that the UHR in active coping strategies was essentially the same as
that of the HC group. This was further supported by a previous study by
Jalbrzikowski et al(Jalbrzikowski et al., 2014), which found that while
the adaptive coping style score remained stable, the type of maladaptive
coping was more likely to change over time in the UHR population.
Jalbrzikowski et al(Jalbrzikowski et al., 2014) simultaneously stated a
similar result that adopting an adaptive coping strategy improved social
functioning while reducing negative symptoms. This was also verified by
the present study that positive correlation across positive coping
methods and SIPS total scores with UHR group together with negative
association across negative coping strategies and SIPS total scores.
We also identified UHR group had resembling negative coping styles with
FEP group, but had more positive coping styles than the FEP group.
Previous findings on the comparison of coping styles between FEP and UHR
were inconclusive. A study has shown that UHR has fewer positive coping
strategies than FEP (Masillo et al., 2012), and it has also been
reported that UHR and FEP had similar patterns in the use of coping
strategies (Pruessner et al., 2011). Schmidt et al(Schmidt, Grunert,
Schimmelmann, Schultze-Lutter, & Michel, 2014)thought that UHR
individuals used fewer active coping strategies such as distraction,
positive self-guidance, situational control, social support, and
minimization than FEP. Positive coping style was also found to be
positively correlated with function in the current study’s FEP Group;
that is, the more positive coping style, the better the function. This
is consistent with previous study(Phillips et al., 2009).
More importantly, Kendler et al(Kenneth et al., 1991) suggested that in
some disorders, coping may be an endophenotype that marks a pathway
through which genetics influences the etiology of psychopathology,
interacting with stress. Previous studies have shown some coping styles,
which have been found to be moderately heritable in the general
population, may be considered as candidate endophenotypes of mental
disorders (Fortgang, Hultman, & Cannon, 2016)(. In this study, the UHR
group was non-help-seeking actively, all derived from first-degree
relatives of schizophrenic patients through researcher’s contact, and
enrolled at an older age, thus may be more in line with presenting
cognitive disease endophenotypes. This also illustrated that negative
coping styles may be an endophenotype of schizophrenia continuum.
However, a recent study showed that coping styles were endophenotypes of
bipolar disorder and depression, but not of schizophrenia (Fortgang et
al., 2016). Similarly, another article showed that individuals at
familial high risk of psychosis had coping styles similar to the normal
population(Piotrowski et al., 2020). Therefore, more studies may be
needed in the future to explore the relationship between coping styles
and endophenotypes.
In the present study depression scores were found to be significantly
higher in the ReSch and FEP groups than in the UHR, and also showed an
effect of depressed mood on coping style, as reflected inside the ANOVA
and logistic regression. This is consistent with previous studies which
showed that patients with schizophrenia were more depressed and took
more negative coping styles and less positive coping styles(Allott et
al., 2015) (Egbe et al., 2014). Emotion-centered coping and avoidance
were also associated with the diagnosis of major depression (Rodgers et
al., 2017). Therefore, it may be possible to develop effective coping
modalities by improving depressive symptoms, thereby reducing positive
symptoms in schizophrenia as well as in UHR.
In terms of coping methods, no major variations were observed across FEP
and ReSch groups which showed that coping mechanisms may already be
severely compromised in FEP patients and do not worsen with time or as
the condition worsens. This gave us suggestions that early
identification and intervention of the impact of coping styles on
schizophrenia patients should be carried out, even in the UHR stage or
even earlier.
On the other hand, this study found that UHR group had extremely higher
self-esteem compared to FEP or ResSch groups, though without significant
differences between UHR and HC groups. This finding contradicted
previous research in some ways. Previous studies(Bemrose et al., 2021;
Park, Bang, Kim, Lee, & An, 2018) found that UHR group demonstrated
severely reduced self-esteem compared to HC group, which was confirmed
by a 2021 meta-analysis (Bemrose et al., 2021).
There could be a number of causes for the contradiction. The UHR
population in this study may not have had enough symptoms to prompt them
to seek help or, as family members of patients with schizophrenia, may
have had a higher tolerance for these unusual psychiatric symptoms
because they were screened from family members of patients with
schizophrenia without seeking help for themselves. Second, given that
the names ”ultra-high-risk psychosis” or ”attenuated psychotic syndrome”
may have stigmatizing effects on individuals (Yang, Wonpat-Borja, Opler,
& Corcoran, 2010), possibly indicating UHR subjects within this
investigation experienced stigmatization of labeling for service use,
resulting in lower self-esteem. Third, the UHR population in the current
study was older, and earlier research has demonstrated that self-esteem
and age were strongly correlated. Self-esteem increases during childhood
and stabilizes (or even declines) in adolescence. It then gradually
rises throughout adulthood before finally declining in later life,
according to previous studies’ finding (Orth, Erol, & Luciano, 2018;
Robins & Trzesniewski, 2005).
A negative correlation between self-esteem and depressive symptoms was
also found in UHR group, with higher self-esteem being linked with fewer
symptoms, which was consistent with earlier research. Pruessner and
colleagues(Pruessner et al., 2011) hypothesized that lower self-esteem
was linked to more severe depressive symptoms. However, it is unclear
whether self-esteem changes at several points of the psychosis continuum
of mental illness, and whether self-esteem can predict UHR individuals’
transformation into psychosis. Future large-scale longitudinal studies
are necessary for assessing relationships across self-esteem and UHR
transformation into psychosis.