1. Introduction
Significant cognitive impairment and functional decline characterize the
prodromal phase of schizophrenia, which is referred to as ultra-high
risk (UHR), also known as psychosis risk syndrome (PRS) or clinical high
risk (CHR) (Modinos & McGuire, 2015). UHR will be used for consistency
in this study. A recent meta-study showed a conversion rate of UHR to
psychosis was 19% in 2 years(Salazar de Pablo et al., 2021). Timely
intervention in UHR is therefore extremely important. Prior research has
demonstrated that CBT-based therapies can lessen the symptoms of UHR,
hence preventing the development of psychotic illnesses(Addington et
al., 2011; Formica et al., 2022; Mei et al., 2021). However, not all UHR
patients benefit from therapy(Stain et al., 2016).
In order to enhance the effectiveness of psychological therapies for
UHR, it may be helpful to establish predictors of treatment response.
According to the vulnerable stress coping model (VSCM) of schizophrenia,
managing stress is a linked component that influences the start and
progression of the disease (Corcoran et al., 2003; Pruessner, Cullen,
Aas, & Walker, 2017). Lazarus identified two differing coping
mechanisms: problem-centric coping and emotion-centric coping (Lazarus,
1998). Problem-centric coping refers to changing the person-relationship
with the environment by changing the situation, while the latter refers
to wishful thinking and tension reduction. In general, problem-centric
coping is thought to be more mature and effective than emotion-centric
coping(Lazarus and Folkman, 1984; Wiedl and Schöttner, 1991).
Maladaptive coping mechanisms, such as self-blame and denial, have been
linked to worse symptoms and worse functional outcomes in both patients
with first-episode (FEP) and chronic schizophrenia patients(Phillips,
Francey, Edwards, & McMurray, 2009)(Phillips et al., 2009; Yanos and
Moos, 2007). Furthermore, the VSCM raises the issue of coping strategy
consistency: whether coping strategies vary across psychosis stages or
are maintained as a personal factor that is stable across all illness
stages, thereby contributing to psychosis vulnerability. Pruessner and
colleagues(Pruessner, Iyer, Faridi, Joober, & Malla, 2011) discovered
that UHR individuals used fewer active coping strategies than FEP and
health controls (HC) ; Lee et al(Lee et al., 2011) reported that UHR and
FEP used coping strategies in similar patterns and Masillo et al(Masillo
et al., 2012) claimed that UHR used more avoidant coping than FEP and
HC. Taken together, there are numerous contentious conclusions about the
UHR’s coping styles.
Thereinto, self-esteem, one of the important features in the
self-system, is considered as a resource for coping with stress, making
it an important determinant to psychological health (Taylor & Stanton,
2007)(Silverstone and Salsali, 2003; Taylor and Stanton, 2007). The
levels of self-esteem influence an individual’s selection of coping
style in stressful situations. Compared with elevated self-esteemed
individuals, those with reduced self-esteem were less inclined for
adopting positive coping styles in response to stress, which incurs
secondary psychological maladaptions (Dai BR et al., 2014). There are
clear evidences indicating reduced self-esteem to be linked to many
psychopathology facets, including etiology, evolution, treatment, and
particularly with some specific symptoms in psychotic patients, such as
hallucinations and delusions (Blairy et al., 2004; Romm et al., 2010).
Self-esteem could influence quality-of-life and functional outcomes of
patients with schizophrenia(Staring, Van der Gaag, Van den Berge,
Duivenvoorden, & Mulder, 2009; Vracotas, Iyer, Joober, & Malla, 2012).
Furthermore, the improvement in coping strategies and alleviation of
patients’ symptoms attributing to psychological interventions on
self-esteem is another provident of the important role of
self-esteem(Gumley et al., 2006; Sonmez et al., 2020). However, at which
stage of mental illness the level of self-esteem starts to change has
not been thoroughly studied. A recent meta-analysis including 6 articles
reported lower self-esteem in the UHR population relative to HC, but
there was large heterogeneity among different literatures(Bemrose,
Akande, & Cullen, 2021).
As a result, the importance of coping styles together with self-esteem
serving to predict morbidity risk within UHR population warrants further
investigation. Furthermore, UHR population research is primarily
hospital-based, with few community-based studies. Previous studies
demonstrated individuals with psychiatric family-histories, have
increased susceptibility for such mental conditions (Pepper & G Cardno,
2014)
Therefore, this investigation was designed for addressing aforementioned
issues due to their clinical importance in at several points of the
psychosis continuum of schizophrenia pathogenesis. Consequently,
comparative analyses for coping styles together with self-esteem in
patients with schizophrenia at various stages, including recurrent
schizophrenia patients (ReSch), FEP, UHR individuals who were all from
first-degree relatives of schizophrenia patients, and therefore also
referred to as genetically high-risk population, together with HC,
having the long-reaching aim of defining efficacious treatment options
for UHR individuals.