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.