Coping With Delusions in Schizophrenia and Affective Disorder With Ps

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Original Paper

Psychopathology 2015;48:11–17 DOI: 10.1159/000363144

Coping with Delusions in Schizophrenia and Affective Disorder with Psychotic Symptoms: The Relationship between Coping Strategies and Dimensions of Delusion

Sarah Rückl a Nana Christina Gentner a Liesa Büche a Matthias Backenstrass a, c Andreas Barthel b Helmut Vedder b Martin Bürgy c Klaus-Thomas Kronmüller a, d

a Department of Psychiatry, University of Heidelberg, Heidelberg , b Psychiatric Center Nordbaden, Wiesloch , c Center of Mental Health, Bürgerhospital, Stuttgart , and d Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, LWL Clinic Gütersloh, Gütersloh , Germany

gaged in more depressive coping. In the schizophrenia spec-trum sample, the action-oriented, the cognitive, and the emotional dimensions of delusion were related to coping factors. In patients with affective disorder, only the action-oriented dimension was related to coping factors. Conclu-

sion: Patients with schizophrenia and affective disorder cope differently with delusions. The dimensions of delusion are related to coping and should be regarded when using cognitive therapy approaches to enhance coping strategies.

© 2014 S. Karger AG, Basel

Introduction

Previous research has demonstrated that both self-generated coping strategies [1–6] and cognitive-behav-ioral interventions that enhance coping strategies [7–11] are effective in the treatment of psychotic symptoms, such as delusions and hallucinations [10] . Given that over half of patients with schizophrenia have persistent or re-curring delusions despite antipsychotic treatment [12, 13] , examining how patients cope with delusions is of great importance. Understanding these coping strategies

Key Words

Affective disorder · Coping · Delusion · Schizophrenia

Abstract

Background: Self-generated coping strategies and the en-hancement of coping strategies are effective in the treat-ment of psychotic symptoms. Evaluating these strategies can be of clinical interest to develop better coping enhance-ment therapies. Cognitive models consider delusions as multidimensional phenomena. Using a psychometric ap-proach, the relationship between coping and the dimen-sions of delusion were examined. Methods: Thirty schizo-phrenia spectrum patients with delusions and 29 patients with affective disorder with psychotic symptoms were inter-viewed using the Heidelberg Coping Scales for Delusions and the Heidelberg Profile of Delusional Experience. Analy-ses of variance were conducted to investigate differences between the groups, and Spearman’s rank-based correla-tions were used to examine the correlations between coping factors and the dimensions of delusion. Results: Schizophre-nia spectrum patients used more medical care and symp-tomatic coping, whereas patients with affective disorder en-

Received: December 12, 2012 Accepted after revision: April 18, 2014 Published online: September 9, 2014

Sarah Rückl Department of Psychiatry University of Heidelberg Vossstrasse 4, DE–69115 Heidelberg (Germany) E-Mail sarah.rueckl @ med.uni-heidelberg.de

© 2014 S. Karger AG, Basel0254–4962/14/0481–0011$39.50/0

www.karger.com/psp

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in schizophrenia and affective disorder with psychotic symptoms can enhance therapeutic approaches to coping for patients who experience stress associated with delu-sions [14] .

Yusupoff and Tarrier [ 10 , p. 86] defined coping as ‘the active self-generation of cognitive and behavioral proce-dures either to impact the symptom directly or to mini-mize the resultant distress’. Lange [3] and Falloon and Talbot [4] published the first empirical studies on self-generated coping strategies in schizophrenia. The advan-tage of studying self-generated coping strategies is that patients are familiar with these strategies as they do not fall outside of the patients’ set of beliefs. These strategies allow patients to make sense of their own reality [15] . Lange [3] described the different coping behaviors of schizophrenic patients for managing the symptoms of schizophrenia, whereas Falloon and Talbot [4] focused on coping with hallucinations in schizophrenia. Both studies demonstrated that schizophrenic patients devel-op coping strategies to master their symptoms. This ap-proach influenced future studies on coping, which have addressed questions regarding how patients cope with their disorders [2, 6, 14, 16–18] , the prodromal phase [19] , and their specific symptoms, including negative symptoms [20] and hallucinations [4, 21] . The results of these studies have indicated that patients with psychosis are actively involved in trying to manage their symptoms [2, 5, 6, 14, 16] .

The use of several strategies has been associated with coping effectiveness [4, 5, 20] . Previous studies have re-ported that patients with schizophrenia apply cognitive strategies to cope with delusions and hallucinations [6, 16, 18] , whereas behavioral strategies are used to deal with other symptoms, such as anxiety, depression, motor retar-dation, and thought disorders [6] . In spite of the amount of research examining coping, there is a lack of research focusing on coping with delusions. There is a definite need for studies comparing patients with schizophrenia and those with affective disorders with psychotic symptoms in the form of delusions. One study by van den Bosch and Rombouts [22] reported no differences between schizo-phrenic patients and patients with depression with regard to coping with problems and unpleasant situations. The aim of the present study was to compare the coping strat-egies used to deal with delusions in patients with schizo-phrenia and patients with affective disorder with psychot-ic symptoms. Recent cognitive models of delusions con-sider delusions to be multidimensional phenomena with cognitive, emotional, and action-oriented dimensions [23–25] . In the present study, cognitive models were in-

corporated in a psychometric approach to examine the relationships between coping and the action-oriented, cognitive, and emotional dimensions of delusion.

Methods

Participants Thirty patients with schizophrenia spectrum disorders experi-

encing delusions and 29 patients with an affective disorder with psychotic symptoms in the form of delusions participated in this study. All of the participants were receiving in-patient treatment at the Department of Psychiatry of the University of Heidelberg, the Psychiatric Center Nordbaden in Wiesloch, or the Center of Mental Health in Stuttgart. Patient diagnoses were determined through a structured clinical interview [26] . Exclusion criteria in-cluded severe medical conditions, neurological disorders, alcohol and drug dependency, and poor German language ability. This study was approved by the local ethics committee and was con-ducted in accordance with the ethical standards established by the Declaration of Helsinki [27] . The sample’s demographic charac-teristics are described in Results.

Procedure The first step in this study was to contact the psychiatrist in

charge to request consent for interviewing target patients. On first contact, an experimenter asked patients if they would like to par-ticipate in this study. Verbal and written information about the study was provided to each patient. Voluntary participation and anonymity were emphasized, and patients were informed that their participation would not influence the psychiatric and psy-chological treatment that they were receiving. After agreeing to participate in this study, patients were required to sign a written consent form. Data collection occurred within the context of a 45-min interview with trained clinical psychologists or psychiatrists who had clinical experience. After a patient’s main delusional be-lief had been identified, the patient was informed that the interview would be about this specific delusional belief. Subsequently, the interviewer completed the Heidelberg Profile of Delusional Expe-rience (unpubl. data). Then, patients were asked about the degree of distress that they experience with their delusional belief, and how much control they had over it. As lists of previously selected strategies can have the disadvantage of concealing strategies that were used successfully, patients were first encouraged to name all of the strategies that they used to manage their beliefs. This proce-dure assures an accurate assessment of the patient’s own experi-ence with a symptom [2] . The answers were then divided and al-located into different categories; for example, if a patient said he isolates himself and avoids other people, this answer was classified as ‘social withdrawal’. It was also inquired as to how often each strategy was used. Then, patients were asked about the 33 pre-defined items of the Heidelberg Coping Scales for Delusions (HCSD). Finally, patients were asked to report their 3 most effec-tive coping strategies.

Instruments Coping strategies were assessed using the HCSD [28] , which is

an established instrument consisting of 33 coping strategies rated on a 5-point Likert scale ranging from ‘not at all’ to ‘very much.’

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The HCSD also assesses the degree of distress caused by the delu-sional belief, the level of control over the delusional belief, and the 3 most effective strategies used to cope with delusions. Two coping indices were calculated to determine how many coping strategies the patients used and how often they used these strategies. The Cop-ing Repertoire Index (CRI) calculates how many strategies the pa-tients use, ranging from 0 (no strategy is used) to 33 (all of the strat-egies are used). The Coping Intensity Index (CII) is the sum of all of the ratings from all of the strategies (coping intensity; CI) divid-ed by the number of strategies used by the patients. The factor-structure of the HCSD was examined using a principal component analysis with a varimax rotation, which yielded the following 5 fac-tors: (1) resource-oriented coping (items: positive reevaluation, self-valorization, enjoyment, prosocial behavior, positive emotions, self-encouragement, humor, and searching for a meaning); (2) medical care (items: medical help, psychotherapy, trusting the ther-apist, medication compliance, disease acceptance, and information seeking); (3) distraction (items: alcohol and drug use, mental dis-traction, sensory distraction, distraction with specific activities, and distraction with unspecific activities); (4) cognitive coping (items: minimization, dissimulation, ignoring, controlling feelings, self-verbalization), and (5) depressive coping (items: social withdrawal, negative emotions, and resigning). The item for symptomatic cop-ing was considered as a separate factor. Symptomatic coping has been defined as behaviors that are used to relieve discomfort, yet they often result in an increased expression of disorder-related be-haviors [6] . The subscales showed internal consistency values rang-ing from α = 0.59 (cognitive coping) to α = 0.83 (resource-oriented coping). The interrater reliability was calculated using intraclass correlation coefficients, and the items showed values between ICC = 0.66 (resigning) and ICC = 0.96 (psychotherapy).

Delusional belief and its dimensions were assessed with the Heidelberg Profile of Delusional Experience (unpubl. data), which is an established rating instrument used to assess and diagnose de-lusional beliefs in psychiatric disorders. A delusional belief was identified and classified according to the Association for Method-ology and Documentation in Psychiatry [29] , and 18 items were to assess delusion formal criteria. The factor-structure of the HPDE was examined using a principal component analysis with a vari-max rotation, which yielded 3 factors [30] . The first factor was the action-oriented dimension and included the items of behavioral impact, pervasiveness of belief, preoccupation, and disruption in life caused by beliefs. The second factor was the cognitive dimen-sion and included the items of conviction, perceptions of others’ views of beliefs, attempts to disprove beliefs, and insight into the delusional belief. The third factor was the emotional dimension and included negative and positive emotions and the distress as-sociated with the delusional belief. The action-oriented dimension showed an internal consistency value of α = 0.78, and both the cognitive and the emotional dimensions had internal consistency values of α = 0.80. The interrater reliability was calculated using intraclass correlation coefficients and the items showed values be-tween ICC = 0.71 (pervasiveness) and ICC = 0.92 (conviction) [31] .

Statistical Analysis One-way analyses of variance (ANOVA) were conducted to iden-

tify differences between the patients with schizophrenia spectrum disorders experiencing delusions and the patients with affective dis-order with psychotic symptoms in the form of delusions. Bonferroni

t tests were used to control for family-wise error. Associations were examined through Spearman’s rank-based correlations. p < 0.05 was considered statistically significant. All analyses were performed us-ing SAS 9.12 (SAS Institute Inc., Cary, N.C., USA).

Results

Sample In the schizophrenia spectrum disorder group, 22 of

30 patients (73.3%) had a diagnosis of schizophrenia, and 8 patients (26.7%) were diagnosed with schizoaffective disorder. Eleven participants were male (36.7%), and 19 participants were female (63.3%). The average age of this patient group was 46.96 years (SD = 12.21). Most patients were single (60%), 40% were employed, and 50% had less than 10 years of secondary education. These patients had experienced an average of 6 (SD = 7.17) hospital psychi-atric treatments. Patients in this group scored an average of 67.5 points (SD = 10.23) on the PANSS total score. The mean level of global functioning, as measured by the Global Assessment of Function (GAF) scale [30] , was 27 (SD = 5.68).

In the affective disorder group, 28 of 29 patients (96.6%) had unipolar depression and were diagnosed with a severe depressive episode with psychotic symp-toms at the time of the investigation. One patient (3.4%) had a bipolar disorder and presented a severe depressive episode with psychotic symptoms. The mean age of the 11 male (38.0%) and 18 female (62.0%) participants with affective disorder was 47.24 years (SD = 12.88). Most pa-tients in this group (65.5%) were married or lived in a partnership, 44.8% were employed, and 55.1% had more than 10 years of secondary education. The mean number of hospital psychiatric treatments was 2.86 (SD = 1.88). Patients with affective disorder scored an average of 67.80 points (SD = 11.95) on the PANSS total score. The level of global functioning in this group of patients averaged 30.96 on the GAF (SD = 11.05). Differences between the groups were examined with one-way ANOVA, and pa-tients with schizophrenia spectrum disorder had a great-er number of hospital psychiatric treatments compared to patients with affective disorder ( table 1 ). There were no differences between the groups with regard to age, GAF scores, or PANSS total scores.

Distress Associated with a Delusional Belief, Control over the Belief, and Coping Patients with affective disorders scored significantly

higher on ratings of distress associated with a delusional

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belief and used more depressive coping to cope with delu-sion compared to the schizophrenia spectrum disorder patients, who used significantly more medical care and symptomatic coping ( table 2 ).

Relationships between the Dimensions of Delusion and Coping Factors For the schizophrenia spectrum disorder sample, the

action-oriented dimension correlated significantly and negatively with cognitive coping. The cognitive dimension of delusion correlated significantly and negatively with re-source-oriented coping, cognitive coping, and the CRI. Moreover, the emotional dimension of the delusional belief showed a significant positive correlation with depressive coping. For the sample of patients with affective disorder, the action-oriented dimension of the delusional belief cor-related significantly and negatively with resource-oriented coping, cognitive coping, and the CII ( tables 3 , 4 ).

Discussion

Patients with schizophrenia used more medical care and symptomatic coping than patients with affective disorder, who were more likely to use depressive cop-ing to deal with their delusional beliefs. These findings suggest that patients’ diagnoses should be taken into consideration when evaluating the self-generated cop-ing strategies they use to deal with delusions. Previous studies have demonstrated that symptomatic coping is the most used strategy in schizophrenic patients [6, 17, 32, 33] . This type of coping strategy is also associ-ated with less control over psychotic symptoms [33] . Bak et al. [32] demonstrated that the use of symptom-atic coping distinguishes psychotic patients with the need for medical care from those without this need. Moreover, patients with schizophrenia are reported to have less supportive social networks, more problem-

Table 1. Sociodemographic and psychopathological characteristics of the sample (n = 60)

Schizophrenia spectrum patients (n = 30)

Affective disorder patients (n = 29)

F(2,58) p

Age, yearsMean 46.96 47.24 0.50 0.60SD (range) 12.21 (22–66) 12.88 (23–71)

Sex, n (%)Male 11 (36.7) 11 (38.0)Female 19 (63.3) 18 (62.0)

Family situation, n (%)Single 18 (60.0) 6 (20.7)Married/partnership 6 (20.0) 13 (44.8)Divorced/widowed 6 (20.0) 10 (34.5)

Secondary education, n (%)≤10 years 15 (50.0) 11 (37.9)>10 years 15 (50.0) 18 (62.1)

Employment situation, n (%)Employed 12 (40.0) 13 (44.8)Unemployed 2 (6.6) 7 (24.1)Retired 11 (36.7) 7 (24.1)Other 5 (16.7) 2 (7.0)

GAFMean 27.0 30.9 1.69 0.19SD (range) 5.68 (15–50) 11.05 (18–68)

Psychiatric treatmentsMean 6.00a 2.86 5.16 0.02SD (range) 7.17 (1–27) 1.88 (1–8)

PANSS total scoreMean 67.50 67.80 0.01 0.92SD (range) 10.23 (51–101) 11.95 (46–93)

a Schizophrenia > affective disorder.

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solving deficits [34] , and impaired cognition [35] , which can also contribute to a greater need for medi-cal care.

In the sample of patients with affective disorders, most (97%) had experienced a severe depressive episode with psychotic symptoms. Studies have demonstrated that pa-tients with milder depressive episodes use more active problem-focused coping, whereas patients with severe de-pressive episodes use more avoidance strategies and emo-tional discharge to deal with stressors [36–38] . In the cur-rent study, we specifically examined the different coping strategies that patients used to deal with delusions and

found that patients with affective disorders used more de-pressive coping, which included strategies such as social withdrawal, isolation, and resignation, than patients with schizophrenia.

Associations between the dimensions of delusions and coping factors were evident for the two groups of patients. For the sample of patients with schizophrenia spectrum disorders, the 3 dimensions of delusion (i.e. action-ori-ented, cognitive, and emotional) correlated significantly with the coping factors, whereas, for the sample of pa-tients with affective disorder, only the action-oriented di-mension showed significant correlations.

Table 2. Comparisons between the groups in terms of distress associated with the delusional belief, control over the belief, and coping

Schizophrenia spectrumpatients (n = 30)

Affective disorderpa tients (n = 29)

F(2,58) p

mean SD me an SD

Distress 2.40 1.22 3.41a 0.73 14.83 0.003Control 0.66 0.99 0.48 0.63 0.71 0.40Coping

Resource-oriented coping 6.90 4.48 8.72 4.56 2.40 0.12Medical care 4.90b 5.39 2.10 2.58 6.39 0.01Distraction 5.23 3.56 4.89 3.58 0.13 0.71Cognitive coping 3.16 2.79 3.03 2.62 0.04 0.85Depressive coping 4.36 3.26 7.44a 3.11 13.76 0.005Symptomatic behavior 1.76b 1.22 1.10 1.37 3.85 0.05CRI 14.36 6.03 14.06 4.09 0.05 0.82CII 2.26 0.48 2.17 0.69 0.32 0.57CI 31.16 11.81 30.30 12.23 0.08 0.78

a Affective disorder > schizophrenia. b Schizophrenia > affective disorder.

Table 4. Spearman’s correlations between coping factors and di-mensions of delusion in the affective disorders group (n = 29)

Action-orienteddimension

Cognitivedimension

Emotionaldimension

Resource-oriented –0.38* –0.05 –0.22Medical care –0.24 –0.18 –0.13Distraction –0.18 0.22 0.07Cognitive coping –0.48** –0.11 –0.19Depressive coping 0.04 –0.11 0.07Symptomatic coping 0.15 0.07 –0.14CRI –0.11 0.13 0.13CII –0.43* –0.24 –0.32

* p < 0.05, ** p < 0.01.

Table 3. Spearman’s correlations between coping factors and di-mensions of delusion in the schizophrenia spectrum group (n = 30)

Action-orienteddimension

Cognitivedimension

Emotionaldimension

Resource-oriented –0.13 –0.39* 0.38*Medical care –0.26 –0.19 –0.14Distraction 0.11 –0.32 0.17Cognitive coping –0.44* –0.58** –0.01Depressive coping 0.13 –0.28 0.56**Symptomatic coping 0.39 0.26 –0.26CRI –0.12 –0.43* 0.21CII –0.10 –0.20 0.02

* p < 0.05, ** p < 0.01.

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Investigation of the relationships between the different dimensions of delusion and coping can guide coping en-hancement therapies to improve cognitive therapy inter-ventions for patients with persistent symptoms. In addi-tion to enhancing coping strategies, the action-oriented, cognitive, and emotional aspects of the delusional belief should be addressed as these aspects can influence the way patients deal with their symptoms [39] . For example, patients whose delusions are associated with great dis-tress used more depressive coping, which can be consid-ered a noneffective coping strategy. Approaching the emotional dimension of the delusion, that is, the emo-tions that are triggered by the beliefs, can change patients’ appraisal of the situation and, consequently, their coping behavior. Yusupoff and Tarrier [10] proposed that the pa-tient’s emotional reactions to the symptoms’ cognitive, physiological, behavioral, and affective components are what define the symptom and create the conditions for maintenance. The Coping Strategy Enhancement (CSE) approach emphasizes identification of the determinants of a symptom, training of effective coping skills, and ex-tension of the established coping methods with patients. A number of studies have shown that CSE can be effective in the treatment of patients with schizophrenia with re-sidual psychotic symptoms [8] and hallucinations [9] .

In conclusion, patients with schizophrenia spectrum disorders and those with affective disorder with psychot-ic symptoms cope differently with delusions. The patients

in the schizophrenia spectrum disorder group were more likely to use medical care and symptomatic coping, whereas patients with affective disorders were more like-ly to use depressive coping. In the schizophrenia group, action-oriented, cognitive, and emotional aspects of the delusions were related to coping, whereas, in the affective disorder group, only action-oriented coping was related to coping. These results suggest that both the enhance-ment of coping strategies and the different dimensions of delusion should be evaluated in patients.

The present study has limitations. The sample was small and only in-patients with acute and severe symptoms were examined. These types of symptoms are usually associated with deficits in adaptive coping [40] . The group of patients with schizophrenia spectrum disorders included patients with schizophrenia and schizoaffective disorder. Although these two diagnoses share common symptoms, patients with schizoaffective disorders also have mood symptoms, which might influence their coping styles. This study was cross-sectional; given that coping and delusions are con-stantly changing phenomena, future longitudinal studies to evaluate changes in coping and delusions over time in both in- and out-patient populations would be of great value. Moreover, coping is a very complex phenomenon that is influenced by factors such the social environment, person-ality, cognition, diagnosis, and symptoms. These findings are preliminary and further research should be conducted to address coping with delusions.

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