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.