Correlates of coping styles in psychotic illness

Recover recovery style from psychosis: a psychometric evaluation of the German version of the Recovery Style Questionnaire (RSQ)

AIMS

The way an individual handles the experience of psychosis, the so-called 'recovery style', has been shown to substantially affect long-term outcomes. The Recovery Style Questionnaire (RSQ) measures this psychological dimension. The aim of this study was to provide a validation of the German version of the RSQ and to raise awareness for recovery-oriented approaches.

METHODS

The RSQ was translated into German according to the guidelines of the WHO and patients were administered this questionnaire and measures of internalised stigma, psychotic symptoms, illness concept, empowerment, self-esteem and quality of life. Descriptive statistics were demonstrated to characterise the sample. Reliability was assessed in different forms: internal consistency, test-retest reliability and split-half reliability. Items were evaluated with descriptive data and item-total correlations. Convergent and discriminant validity were shown, and a confirmatory factor analysis was performed. In order to ameliorate the model, a post hoc model modification was done.

RESULTS

The sample consisted of 138 patients diagnosed with schizophrenia spectrum disorders (mean age: 35.7 years; 53.6% men; mean duration of illness: 20.6 years) with a mean RSQ overall percentage of 66.12 (s.d. ± 17.43%), mainly representing the categories 'mixed picture' and 'tends towards integration'. The reliability of the RSQ was acceptable with a Cronbach's α of 0.741 and a test-retest coefficient of 0.502. Item-total correlations were not acceptable for 27 of 39 items. Moderate evidence for convergent validity of the RSQ was found. Confirmatory factor analysis revealed that the 13-factor model with 39 items originally proposed was partially poorly replicated in the present sample (χ2 ratio to degrees of freedom (χ2/df) of 1.732, Comparative Fit Index (CFI) of 0.585, Normed Fit Index (NFI) of 0.414, Tucker-Lewis Index (TLI) of 0.508, root mean square error of approximation (RMSEA) of 0.095). The RSQ was modified based on item-total correlations and path coefficients of the single items. The confirmatory factor analysis of the resulting one-factor model with 11 items showed adequate fit to the data (χ2/df of 1.562, CFI of 0.936, NFI of 0.847, TLI of 0.910, RMSEA of 0.083) and demonstrated good model fit.

CONCLUSIONS

Despite partially insufficient psychometric data of the original RSQ, the concept of recovery style is beneficial to psychiatric research and clinical practice. The underlying idea is valuable, and the questionnaire needs further development. Therefore, a short version of the RSQ is proposed.

Qualitative exploration of the effect of a television soap opera storyline on women with experience of postpartum psychosis

BACKGROUND

Postpartum psychosis has recently been the focus of an in-depth storyline on a British television soap opera watched by millions of viewers.

AIMS

This research explored how the storyline and concomitant increase in public awareness of postpartum psychosis have been received by women who have recovered from the condition.

METHOD

Nine semistructured, one-to-one interviews were conducted with women who had experienced postpartum psychosis. Thematic analysis consistent with Braun and Clarke's six-step approach was used to generate themes from the data.

RESULTS

Public exposure provided by the postpartum psychosis portrayal was deemed highly valuable, and its mixed reception encompassed potentially therapeutic benefits in addition to harms.

CONCLUSIONS

Public awareness of postpartum psychosis strongly affects women who have experienced postpartum psychosis. This research highlights the complexity of using television drama for public education and may enable mental health organisations to better focus future practices of raising postpartum psychosis awareness.

DECLARATION OF INTEREST

GB is chair of action on Postpartum Psychosis. JH is director of action on Postpartum Psychosis. IJ is a trustee of action on Postpartum Psychosis and was a consultant to the BBC (television company) on the EastEnders storyline. CD is a trustee of action on Postpartum Psychosis, a trustee of BIPOLAR UK, vice chair of the Maternal Mental Health Alliance, and was a consultant to the BBC (television company) on the EastEnders storyline.

The impact of thought disorder on therapeutic alliance and personal recovery in schizophrenia and schizoaffective disorder: An exploratory study

Thought and language disorders are a main feature of schizophrenia. The aim of the study is to explore the impact of thought disorder on therapeutic alliance and personal recovery because of its interference with verbal communication. Thought disorder, positive and negative symptoms (Positive and Negative Syndrome Scale), functioning (Modified Global Assessment of Functioning scale), insight (Scale to Assess Unawareness of Mental Disorder), attachment insecurity (Psychosis Attachment Measure), therapeutic alliance (Scale to Assess the Therapeutic Relationship), and personal recovery (Recovery Assessment Scale, Integration Sealing-Over Scale) were assessed in 133 outpatients with schizophrenia or schizoaffective disorder at baseline and twelve months later. The data were analyzed by hierarchical multiple linear regression. Higher levels of thought disorder were significantly associated with lower clinicians' ratings, but not with patients' ratings of therapeutic alliance. In addition, lower clinicians' ratings of therapeutic alliance were significantly linked to a more sealing over and less integrative recovery style. In fact, the lower therapeutic alliance ratings mediated the association between thought disorder and a sealing over recovery style. The results highlight the importance of considering thought disorder in treatment of schizophrenia and schizoaffective disorder which may interfere with therapeutic alliance and treatment efforts towards recovery.

New perspectives on schizophrenia in later life: implications for treatment, policy, and research

Worldwide, in the past few decades, the demographics of older people (ie, people 55 years and over) with schizophrenia have changed completely with respect to absolute numbers of people affected, the proportion of all people with the disorder, life expectancy, and residential status. The ageing schizophrenia population has created vast health-care needs and their medical comorbidity contributes to higher mortality than in the general population. Proposals to classify schizophrenia into early-onset, late-onset, and very-late-onset subtypes now should be tempered by the recognition that comorbid medical and neurological disorders can contribute to psychotic symptoms in later life. The concept of outcome has become more nuanced with an appreciation that various outcomes can occur, largely independent of each other, that need different treatment approaches. Data show that schizophrenia in later life is not a stable end-state but one of fluctuation in symptoms and level of functioning, and show that pathways to improvement and recovery exist. Several novel non-pharmacological treatment strategies have been devised that can augment the clinical options used to address the specific needs of older adults with schizophrenia.

Service engagement: psychopathology, recovery style and treatments

The aim of the present study is to evaluate how recovery style, a set of strategies used by patients to interact with services and therapists, and the severity of psychotic symptoms affect the quality/continuity of taking charge of each patient. 156 psychotic patients at different stages of illness were enrolled. Sociodemographic and clinical data were collected and integration/sealing-Over Scale, Recovery Style Questionnaire and Positive and Negative Syndrome Scale were administered. Patients were distinguished into four groups according to the type of treatment received: clinical package, hospital package, day-care package, and residential package. A positive correlation between the cost of psychiatric performance and psychopathological severity (measured with PANSS scores) was identified. No association emerged between ISOS/RSQ total scores and costs. The sanitary expenditure appears to be linked to positive psychotic symptoms while lower performances are given for the treatment of patients with predominant negative symptoms. Recovery style itself has not a direct influence on the quantity/quality of psychiatric services.

Prevalence of negative symptoms and associated factors in older adults with schizophrenia spectrum disorder

OBJECTIVE

To examine the prevalence of negative symptoms and associated factors in older adults with schizophrenia spectrum disorder living in the community.

METHODS

The sample consisted of a multiracial sample of 198 persons aged 55 and more with a schizophrenia spectrum disorder that developed the disorder before the age of 45; 39% and 61% lived independently and in supported community residences, respectively. George's Social Antecedent Model of Psychopathology was used to examine 16 predictor variables of negative symptoms, based on scores of 4 or more on any of the PANSS negative symptom items.

RESULTS

Forty percent of the sample met the criteria for the presence of negative symptoms, and this decreased to 19% when potential secondary symptoms were excluded. In bivariate analysis, 10 variables were found to be significantly associated with the presence of negative symptoms, but when the model was tested in logistic regression analysis, only 3 variables retained significance: greater positive symptom scores (odds ratio [OR] = 1.26), lower cognitive scores (OR = 0.96), and fewer confidantes (OR = 0.80).

CONCLUSION

Negative symptoms do not dominate the clinical picture in later life, and levels of negative symptoms appear to be no higher than in younger schizophrenia populations. The relative paucity of significant variables and their modest effect sizes suggest that treatment for negative symptoms in later life will depend largely on strategies directed specifically at the negative symptoms.

Recovery style predicts remission at one-year follow-up in outpatients with schizophrenia spectrum disorders

Although people with schizophrenia use various coping strategies, it is largely unknown how their coping style contributes to remission of the illness. The concept of recovery style-either by sealing over or integrating-reflects an important distinction. We wanted to examine whether recovery style predicts remission at a 1-year follow-up. We examined the recovery style, insight, therapeutic alliance, and symptoms in 103 patients with psychotic disorders. To assess the remission status, the symptoms were measured at 6 and 12 months. Logistic regression analyses were used. Results showed that scoring an extra category toward integration (six categories exist) increased the odds of remission 1.84-fold (95% confidence interval, 1.11 to 3.03). Insight and therapeutic alliance were not predictive. Although remission was also predicted by positive symptom levels at baseline, this did not influence the effect of recovery style. In conclusion, independently of symptom levels, insight, or therapeutic alliance, an integrating recovery style increases the odds of remission at a 1-year follow-up.

Comparison of recovery style and insight of patients with severe mental illness in secure services with those in community services

Insight and recovery style have long been associated with Severe Mental Illness (SMI) but there remains little understanding of the relationship between how individuals comprehend and react to their illness and whether this reaction has a subsequent impact on where they receive treatment. Patients receiving treatment for SMI in two different locations, community services and long-term secure services were compared on their Recovery Style and Insight. This study hypothesizes that patients with SMI who receive treatment in secure services do so because they have poor insight into their illness and adopt a 'sealing over' recovery style. A significant difference in insight was found. The community group recorded higher insight than those in the secure group. Recovery style was found to relate to insight but not to service provision. This difference may provide an explanation of how insight and recovery style contributes to the recovery process and why some people do not respond well to the traditional medical approach to their illness. Further research is required to explore these possibilities but early indications are that services could benefit from the assessment of insight and recovery style at the baseline assessment stage to support early treatment formulation.

Correlates of coping styles in psychotic illness -- An extension study

Coping/recovery styles of integration and sealing over, reflecting the patient's dealing with his or her psychotic illness, influence the treatment adherence and, perhaps, the therapy outcome. Knowledge of these styles' potential clinical and personality correlates is so far limited. A semi-structured interview and self-rating questionnaires were used to assess 64 inpatients recovering from an acute episode of a schizophrenia spectrum disorder with regard to the prevailing coping/recovery style, depressive and negative syndromes, global functioning, locus of control and personality characteristics of novelty seeking, harm avoidance, and reward dependence. A significant positive correlation was found between coping/recovery style of sealing over and both negative syndrome and external control (by powerful others) orientation; a significant negative correlation was found between sealing over and good global functioning. The final multivariate model comprised negative syndrome, global functioning and a personality characteristic of reward dependence; together these three variables explained 44% of the coping/recovery style variance. Thus, in patients with disorders in the schizophrenia spectrum, the inclination towards sealing over is positively correlated with the higher degree of the overall severity of psychiatric disturbance and it is closely associated with a negative syndrome. In contrast, both the degree of depression and personality characteristics measured do not seem to play an important role with regard to the prevailing coping/recovery style of integration and sealing over.

The role of effort, cognitive expectancy appraisals and coping style in the maintenance of the negative symptoms of schizophrenia

The aim of the present study was to assess the role of psychological factors, specifically effort, coping, and negative expectancy appraisals, in addition to executive functioning and depression, in accounting for negative symptoms broadly defined. Fifty inpatients with acute schizophrenia participated in a study with a cross-sectional design. All of the psychological variables had significant partial correlations with some of the measures of negative symptoms when depression was controlled. A series of multiple regression analyses indicated that executive functioning only made a significant unique contribution to the prediction of affective flattening, whereas psychological factors made unique contributions to the variance in each of the negative symptom subscales apart from affective flattening, as well as to the negative symptom total score, accounting for 9% to 19% of the variance. These results suggest that, in addition to neuropsychological variables, psychological variables are important for understanding negative symptoms in acute schizophrenia.

The differentiation between 'lack of insight' and 'dysfunctional health beliefs' in schizophrenia

BACKGROUND

'Lack of insight' into one's own illness is a frequent symptom in schizophrenic disorders. 'Health beliefs' are psychological explanations of one's own health status and are held by all individuals. The question is how they relate to each other.

METHODS

Lack of insight (according to the definition of the AMDP System) and health beliefs (measured with the Illness Concept Scale) were assessed in 364 schizophrenic outpatients who participated in a study on neuroleptic long-term treatment.

RESULTS

'Insight into illness' and 'health beliefs' are independent of each other. Insight is related to the current psychopathological status as measured by the Brief Psychiatric Rating Scale, whereas health beliefs are related to personal life experiences. Lack of insight and dysfunctional health beliefs are both associated with patient noncompliance.

CONCLUSION

Poor insight and dysfunctional health beliefs are separate clinical phenomena. Making this distinction is important for guiding research and patient care.

Association of neurocognition, anxiety, positive and negative symptoms with coping preference in schizophrenia spectrum disorders

It is recognized that persons with schizophrenia tend to cope with stress in a relatively avoidant and ineffectual manner and that this coping style is linked to poorer outcome. Less is understood, however, about the interrelationship between symptoms, deficits in neurocognition and coping style in schizophrenia. To determine the extent to which various neurocognitive deficits and symptoms are related to coping style in schizophrenia, measures of positive symptoms, negative symptoms, state and trait anxiety levels, verbal memory and executive function were correlated with self-report of preference for a range of active and avoidant coping strategies. Participants were 42 persons with schizophrenia spectrum disorders enrolled in outpatient psychiatric care. Stepwise multiple regressions indicated that greater preferences for taking action when faced with a stressor were significantly (p<.05) linked to lesser positive symptoms and lesser state anxiety while greater preferences for thinking or talking about possible solutions were linked to lesser impairments in neurocognition. A greater preference for resigning in the face of stress was significantly linked to greater levels of negative symptoms and trait anxiety, while a preference to ignore stressors was linked to both greater levels of positive symptoms and graver impairments in neurocognition. Implications for understanding the genesis of psychosocial dysfunction and for the development of rehabilitative interventions are discussed.