Schizophrenia Research 175 (2016) 129135

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Schizophrenia Research

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Dysfunctional coping with stress in psychosis. An investigation with the

Maladaptive and Adaptive Coping Styles (MAX) questionnaire
Steffen Moritz a, Thies Ldtke a, Stefan Westermann b, Joy Hermeneit a, Jessica Watroba a, Tania M. Lincoln c
a
Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
b
Department of Clinical Psychology and Psychotherapy, University of Bern, Switzerland
c
Department of Psychology, University of Hamburg, Germany

a r t i c l e i n f o a b s t r a c t

Article history: Objective: Psychotic episodes have long been conceptualized as inevitable incidents triggered by endogenous bi-
Received 13 January 2016 ological impairments. It is now well-accepted that the ability of an individual to deal with social and environmen-
Received in revised form 7 April 2016 tal challenges plays an important role in regard to whether or not a vulnerability to psychosis translates into
Accepted 18 April 2016 symptoms. For the present study, we examined symptomatic correlates of dysfunctional coping in psychosis
Available online 18 May 2016
and aimed to elucidate a prole of coping strategies that distinguishes patients with schizophrenia from those
with depression.
Keywords:
Coping
Method: The newly devised Maladaptive and Adaptive Coping Styles Scale (MAX) was administered to 75 indi-
Schizophrenia viduals with psychosis, 100 individuals with depression and 1100 nonclinical controls.
Depression Results: Schizophrenia patients showed compromised coping abilities relative to nonclinical controls, particularly
Positive symptoms a lack of engaging in adaptive coping. Depression was more closely tied to dysfunctional coping than were pos-
Emotion regulation itive symptoms as indicated by group comparisons and correlational analyses. Correlations between positive
symptoms, particularly paranoid symptoms, and avoidance and suppression remained signicant when depres-
sion was controlled for.
Conclusions: Although maladaptive and adaptive coping are unlikely to represent proximal mechanisms for the
pathogenesis of positive symptoms, fostering coping skills may reduce positive symptoms via the improvement
of depressive symptoms, which are increasingly regarded as risk factors for core psychotic symptoms. Further-
more, the reduction of avoidance and suppression may directly improve positive symptoms.
2016 Published by Elsevier B.V.

1. Introduction fully unraveled and research is beginning to focus more on predisposing

factors that may act as moderators or mediators between stressors and
1.1. Stress and psychosis symptoms (Lincoln et al., 2010, 2009; Moritz et al., 2015, 2011).

The term schizophrenia was initially coined as a plural diagnostic en-
tity (i.e., the schizophrenias) highlighting the heterogeneous phenome-
nology of the disorder (Bleuler, 1950). Core features encompass
positive symptoms as well as negative, disorganized and affective
symptoms (American Psychiatric Association, 2013). In view of the stig-
ma associated with the diagnosis, which is often confused with split
personality and equated with erratic and violent behavior (McNally,
2010; Schlier and Lincoln, 2013), clinicians have increasingly begun to
abandon the term schizophrenia and to replace it with the yet unofcial
label (non-affective) psychosis. Under the inuence of the vulnerability-
stress model, Japan even went a step further and renamed schizophre-
nia to integration disorder (Togo Shitcho Sho; Sato, 2006).
The vulnerability-stress model (Nuechterlein and Dawson, 1984;
Zubin and Spring, 1977) posits that an acute episode only occurs if the
level of stress exceeds the amount an individual can bear depending on
his or her liability to psychosis. Despite the heuristic value of this account,
the exact mechanisms that translate stress into psychosis have not been
1.2. Coping and emotion regulation strategies in psychosis
Coping/emotion regulation is increasingly examined in psychosis.
Coping is aimed at regulating emotional experiences by changing
one's response to a stressful event (emotional coping/emotion regula-
tion) or by changing the stressful situation itself (Compas et al., in
press). Research traditionally distinguishes adaptive versus maladap-
tive coping (Aldao et al., 2010; Moritz et al., 2016), whereby the specic
context determines whether a style is functional or dysfunctional
(Aldao, 2013). Coping has been most extensively researched in depres-
sion and anxiety and studies suggest that mood disorders are strongly
associated with maladaptive forms of coping (Moritz et al., 2016), for
example rumination (Olatunji et al., 2013). Whether or not a coping
pattern is specic for a certain disorder is subject of an ongoing debate
(Aldao and Nolen-Hoeksema, 2010; Aldao et al., 2010) and the question
is complicated by the fact that most studies only assessed single disor-
ders (Aldao, 2013). Complicating things further, we must take into

http://dx.doi.org/10.1016/j.schres.2016.04.025
0920-9964/ 2016 Published by Elsevier B.V.
130 S. Moritz et al. / Schizophrenia Research 175 (2016) 129135
account that coping styles are likely to be related to different symptoms
for different reasons. Withdrawal/avoidance may foster depression and
anxiety because of the feeling of loneliness but may also induce para-
noia (Freeman et al., 2005), for example because correcting social feed-
back is lacking and correcting experiences are not made (Moutoussis
et al., 2007).
Research into coping and emotion regulation in schizophrenia
shows that patients engage in maladaptive coping, for example, exces-
sive avoidance and safety behavior (Freeman et al., 2007) as well as
emotion and thought suppression (Kimhy et al., 2012; Livingstone
et al., 2009; van der Meer et al., 2009). Lack of awareness and tolerance
of emotions is also prominent (Kimhy et al., 2012; Lincoln et al., 2015a,
b; van der Meer et al., 2009).
The urge to control (or suppress) one's (negatively valenced)
thoughts or emotions has been linked to positive symptoms and partic-
ularly hallucinations (de Leede-Smith and Barkus, 2013; Jones and
Fernyhough, 2006; Moritz et al., 2010; Morrison and Wells, 2003).
This might be explained by the well-documented observation that sup-
pression paradoxically enhances negative thoughts (Wenzlaff and
Wegner, 2000). While in depressed patients this may increase depres-
sive symptoms and helplessness, it could create a tug war with voices
in those with psychosis (once I try to resist the voices, the voices strike
back and become louder).
A recent review and meta-analysis (O'Driscoll et al., 2014) on coping
in schizophrenia found that attentional deployment (e.g., rumination,
worry), dissociation and alexithymia were positively associated with
schizophrenia, whereas the ability to manage emotions was negatively
associated with schizophrenia at a large effect size. Lincoln et al.,
(2015a,b) found that participants with psychosis reported a stronger in-
crease in self-reported stress in response to a stressor than healthy con-
trols which was in turn predicted by a reduced awareness of and
tolerance for distressing emotions. Another study (Westermann et al.,
2014) suggests that researchers should not only assess whether or not
a coping strategy (e.g., reappraisal) is used but also if it is adopted suc-
cessfully (see also Moritz et al., 2016); nonclinical delusion-prone indi-
viduals were found to be less successful in applying reappraisal
(Westermann et al., 2014), which was, however, not conrmed in pa-
tients with manifest psychosis (Grezellschak et al., 2015).
The inferences that can be drawn from the available body of research
are promising but limited by a number of factors. Firstly, the specicity
of coping dysfunctions in psychosis is not fully established as individuals
with psychosis were often tested against nonclinical (van der Meer
et al., 2009) but not against clinical controls (e.g., depressive patients)
(however see Kimhy et al., 2012; Lincoln et al., 2015a,b) and the effects
of general psychopathology, particularly depression, were not always
considered (O'Driscoll et al., 2014). Secondly, results are inconsistent
across participants with varying levels of liability to psychosis. As
shown, nonclinical controls scoring high on psychosis proneness scales
may display different responses and coping patterns than individuals
who fulll diagnostic criteria for psychosis requiring treatment (de
Leede-Smith and Barkus, 2013). Of concern, the latter aspect, treatment
status, may inuence coping in opposing ways. Hospitalization may
both promote certain dysfunctional coping strategies (e.g., passivity
due to restricted and shielded environment) versus foster engagement
in functional strategies (e.g., because of psychoeducational groups
teaching patients new skills) thereby reducing the stability of ndings.
Thirdly, while research conrms that coping may play a role in the for-
mation of paranoia (Westermann and Lincoln, 2011; Westermann et al.,
2013, 2012), the specicity of these ndings is unclear.
1.3. Maladaptive and Adaptive Coping Styles Questionnaire (MAX)
We recently constructed a brief coping scale termed Maladaptive
and Adaptive Coping Questionnaire (MAX; Moritz et al., 2016) which
encompasses three subscales (maladaptive coping, adaptive coping,
avoidance) covering a range of traditional coping styles (e.g., problem-
solving, rumination) as well as styles of emotion regulation that have
recently received more attention (e.g., acceptance). We developed a
new scale rather than combining established ones as existing scales
often tap single constructs and measures vary according to wording, re-
sponse options, and also time frame (one week, lifetime etc.) which im-
pacts on the respective reliabilities and validities. For this reason,
correlations with, for example, specic psychopathological scales will
mirror both conceptual but also methodological differences.
The MAX was recently validated in a large population sample (N =
2200) and found to yield good psychometric properties. The adaptive
( = 0.87) and maladaptive ( = 0.85) coping subscales showed
high internal consistency; the avoidance subscale was somewhat less
consistent ( = 0.65). The six-months test-retest reliability was espe-
cially high for maladaptive coping (maladaptive coping: r = 0.75,
p b 0.001; adaptive coping: r = 0.61, p b 0.001; and avoidance:
r b 0.59, p b 0.001) conrming recent reports that maladaptive coping
is more stable than adaptive coping (Aldao, 2013). Maladaptive coping
was also more strongly related to well-being (negative relationship)
than adaptive coping (positive relationship) both cross-sectionally and
longitudinally. Overall, depressive symptoms more highly correlated
with dysfunctional coping than paranoia and obsessive-compulsive
symptoms. However, results await to be tested in a clinical population.
In another study (Dietrichkeit, 2015) the MAX was signicantly corre-
lated with the Brief COPE Inventory (Carver, 1997) in depressed
patients.
1.4. The present study
For the present study, we compared a sample of individuals with
psychosis to patients with depression and nonclinical controls. Patients
with depression can be regarded as an ideal control group for psychosis
as despite high comorbidity (Buckley et al., 2009) core diagnostic
features are different. In contrast, other disorders, especially
obsessive-compulsive disorder (OCD), bipolar disorder and anxiety dis-
orders including trauma, show some symptomatic overlap with psycho-
sis as to core symptoms (e.g., a diagnosis of OCD now also includes
patients with low insight who sometimes show delusional features;
anxiety disorders and psychosis often share great fear; many bipolar pa-
tients have delusions). We hypothesized that both individuals with psy-
chosis and individuals with depression would show more dysfunctional
and less functional coping than nonclinical controls and that the rela-
tionship would be especially pronounced for depressive symptoms
(across all populations) against the background that depression has
emerged as the strongest correlate of coping in studies (e.g., Moritz
et al., 2016). Inconsistent associations across studies for coping behavior
and positive symptoms relative to depressive symptoms may, however,
be due to the fact that different positive symptoms (e.g., paranoid delu-
sions, grandiosity, hallucinations) are usually pooled to one score
(e.g., in the Positive and Negative Syndrome Scale), although there is
ample evidence now that the positive syndrome is heterogeneous
(Peralta and Cuesta, 1999; Schlier et al., 2015; van der Gaag et al.,
2006) and its components may have different etiologies (e.g., Bentall
et al., 2014; Zavos et al., 2014). We therefore looked at single positive
symptoms more closely by making use of the multidimensional struc-
ture identied for the Community Assessment of Psychic Experiences
Scale (CAPE; Schlier et al., 2015). No predictions were made whether
a distinct prole could be elucidated for patients with psychosis versus
those with depression as most studies compared patients with schizo-
phrenia to nonclinical controls only (O'Driscoll et al., 2014).
2. Methods
2.1. Sample
Participants were sought from different sources (see below). All
were invited to participate in an anonymous online survey which was
 S. Moritz et al. / Schizophrenia Research 175 (2016) 129135
set up using unipark/questback (Globalpark AG). Patients were guid-
ed through the survey via online instructions. No personal support
was provided by the experimenters. No nancial compensation was of-
fered. The research was carried out in accordance with the Declaration
of Helsinki. All participants provided electronic informed consent before
participation. A number of general inclusion criteria were applied. Blind
to results, participants who had entered the same value throughout the
psychopathology assessment as well as participants beyond 18 and
70 years of age were excluded. Multiple log-ins using the same comput-
er were precluded via cookies. The survey consisted of the following
parts: demographic section (e.g., gender, age), medical history
(e.g., diagnosis of a mental disorder, if applicable), profession of the per-
son who had diagnosed the disorder (if applicable), assessment of psy-
chopathology and coping (see questionnaires section below).
Nonclinical controls were recruited via WisoPanel, a service pro-
viding scientists with the opportunity to advertise non-commercial
studies (for the reliability of this and related services see Gritz, 2007,
2009; Judge et al., 2006; Piccolo and Colquitt, 2006). The present
study examined a subsample of a nonclinical population already report-
ed in our forerunner study (Moritz et al., 2016). We excluded individ-
uals with a history of mental disorder and Patient Health
Questionaire-9 (PHQ-9; Kroenke et al., 2001) scores greater than 9
points (cut-off for mild to moderate depression). Moreover, we took
care that the sample showed similar background characteristics to the
clinical groups by applying an iterative reduction of the sample blind
to results in the primary outcomes.
The depressed sample was drawn from of a multi-center trial com-
paring the effects of a psychological online intervention with a care-
as-usual control condition (Klein et al., 2013; Moritz et al., 2014). For
the present study, only baseline data were considered. Patients met
criteria of mild to moderate depression, as indexed by the PHQ-9
(Kroenke et al., 2001). Patients also had to fulll criteria for either de-
pression or dysthymia that were assessed by the Mini International
Neuropsychiatric Interview (MINI; Sheehan et al., 1998), which was
conducted via telephone after the baseline online assessment. This
was complemented by information from the Web Screening Question-
naire (WSQ; Donker et al., 2009) and by participants' reports of having
received a prior diagnosis of depression or dysthymia by a mental
health specialist. In this sample, patients with a history of psychosis or
bipolar disorder (via screening information from the MINI interview)
and acute suicidal tendencies (by means of the Suicide Behavioral
Questionnaire-Revised; Osman et al., 2001) were excluded. A total of
82% of the individuals with depression were prescribed medication
(mainly antidepressants).
Table 1
Group differences on demographic, psychopathological and coping variables.
Variables Nonclinical (N; n = 1100) Depression (D; n = 100)
Background
Age in years 41.96 (11.35) 42.59 (10.47)
Gender (% female) 68% 77%
Education (%13th grade) 93% 91%
Psychopathology
PHQ-9 3.26 (2.62) 10.96 (2.31)
CAPE positive
CAPE negative
CAPE depressed
MAX subscales
Adaptive coping 2.90 (0.60) 2.40 (0.41)
Maladaptive coping 2.03 (0.59) 2.93 (0.40)
Avoidance 2.29 (0.68) 2.70 (0.61)
131
The psychosis sample was mainly comprised of former inpatients at
the Department of Psychiatry and Psychotherapy at the University
Medical Center Hamburg-Eppendorf (Germany, UKE) who had formally
been diagnosed with schizophrenia and who had given written in-
formed consent to be re-contacted for future studies. We also posted
advertisements in moderated online discussion forums for psychosis;
all were required to have an externally veried diagnosis of schizophre-
nia/psychosis (patients with bipolar disorder without a concomitant
history of schizophrenia or schizoaffective disorder were excluded). It
becomes clear from Table 1 that the psychosis sample was character-
ized by few positive symptoms, whereas negative and depressive symp-
toms were more pronounced typical of an outpatient sample. A total of
91% of the individuals with depression were prescribed medication
(mainly antipsychotic agents).
2.2. Questionnaires
2.2.1. Maladapative and Adaptive Coping Style (MAX) Questionnaire
Maladapative and Adaptive Coping Style Questionnaire (MAX)
covers major adaptive and maladaptive coping styles. Item composition
was largely inspired by a study conducted by Aldao and Nolen-
Hoeksema (2012a) and supplemented by additional coping styles. Ini-
tially, we construed 10 pairs of opposite items (e.g., I try to stay re-
laxed (helpful) versus I emotionally overreact quickly (unhelpful));
only the acceptance item had no counter-part. Items had to be en-
dorsed on a 4-point Likert scale: not true (=1), rather not true (=2),
rather true (= 3), true (= 4). A factor analysis using the original 21
MAX items suggested a three-dimensional structure: Adaptive Coping
(9 items), Maladaptive Coping (7 items) and Avoidance (3 items).
Two items could not be allocated to any of the scales according to our
factor analysis including the item I try to suppress negative thoughts.
As thought and emotion suppression is considered relevant to the for-
mation of positive symptoms (see Introduction), we also calculated a
subscale labeled Suppression encompassing both cognitive and emo-
tion (expressive) suppression which consisted of three items (I try to
suppress negative thoughts.; I put on a good face and hide my true
feelings. and I always keep my problems to myself and do not share
them with others). The instruction was as follows:
Individuals differ in how they deal with stress. While some people
do not lose their inner balance even when faced with serious prob-
lems at work or at home, others react with signicant psychological
distress. We are interested in how you experience and deal with
problematic situations. Please respond in a way that reects best
Psychosis (P; n = 75) Statistics (df = 2, 1559)
40.89 (9.41) F (2,1274) = 0.50, p = 0.607
64% 2(2) = 4.39, p = 0.114
Not assessed 2(1) = 0.54, p = 0.469
8.31 (5.55) F (2,1274) = 417.72, p b 0.001; D N P N N (all p b 0.001)
1.28 (0.35)
2.26 (0.72)
2.17 (0.83)
2.60 (0.56) F (2,1272) = 39.456, p b 0.001; N N P (p b 0.001);
P N D (p = 0.025); N N D (p b 0.001)
2.45 (0.69) F (2,1272) = 156.92, p b 0.001; D N P (p b 0.001);
P N N (p = 0.092); D N N (p b 0.001)
2.45 (0.69) F (2,1272) = 18.39, p b 0.001; D N P (p = 0.015);
P N N (p = 0.046); D N N (p b 0.001)
132 S. Moritz et al. / Schizophrenia Research 175 (2016) 129135

how you actually react and feel in stressful situations. Do not re-
spond in a way that reects how you would like to react in the future
or would have preferred to react in retrospect. Please report your
true emotions and reactions.
with depression displayed higher depression scores (corresponding to
a mild to moderate degree) than both nonclinical individuals and indi-
viduals with psychosis.
3.2. Group differences on coping

2.3. Psychopathology
All groups received the Patient Health Questionnaire (PHQ-9;
Kroenke et al., 2001) which is a self-report instrument derived from
the Primary Care Evaluation of Mental Disorders (PRIME-MD; range:
027). Its nine items tap the DSM diagnostic criteria of depression (re-
sponse options: not at all (=0), several days (=1), more than half the
days (= 2), nearly every day (= 3)). Its psychometric properties can
be judged as good with a sensitivity of 0.80 and a specicity of 0.92
(Gilbody et al., 2007).
The Community Assessment of Psychic Experiences Scale (CAPE;
Stefanis et al., 2002) assesses symptoms of psychosis. While it was ini-
tially developed for assessing attenuated/subclinical symptoms of psy-
chosis in the general population, it is increasingly utilized in patient
samples (Schlier et al., 2015). Items are rated on a four-point Likert
scale (Never (1), Sometimes (2), Often (3) and Nearly always
(4)). The CAPE was slightly revised to measure symptoms experienced
during the last week. The original version of the CAPE measures three
syndromes: positive, negative, and depressive. The reliability and (fac-
torial) validity of the scale are good (Konings et al., 2006; Stefanis
et al., 2002). A recent study (Schlier et al., 2015), however, suggests
that a multidimensional model (see Table 2 for its subscales), which
splits positive and negative symptoms into several subdomains, shows
better comparative t than the three-factor model.
3. Results
3.1. Background variables
Table 1 shows that the three diagnostic groups were comparable as
to their demographic background characteristics. As expected, patients
Individuals with depression were the only group that displayed less
adaptive than maladaptive coping (see Table 1). This group showed de-
viant scores indicative of dysfunctional coping relative to both other
groups on all three MAX subscales. Numerically, psychosis patients
scored in-between for all MAX subscales (this was also true for each
of the MAX items) and signicantly differed from nonclinical controls
on adaptive coping and avoidance.
Table 2 shows that in participants with psychosis maladaptive and
adaptive coping were strongly related to depression severity, as indexed
by both the PHQ-9 and the CAPE depression subscale. A test for correla-
tional differences (Steiger, 1980) indicated that these correlations were
signicantly stronger than those seen for the CAPE positive dimension
(traditional algorithm, p b 0.05). When PHQ-9 scores were controlled
for, none of the correlations between the positive syndrome (traditional
algorithm) and the negative syndrome with maladaptive and adaptive
coping retained signicance.
We then examined correlations for the newly composed CAPE sub-
scales (Schlier et al., 2015). With the exception of grandiosity (weak
correlations), all symptom features showed modest correlations with
avoidance and suppression. When depression was controlled for, the
correlations between positive (traditional algorithm) and paranoid
symptoms with avoidance and suppression remained signicant (r =
0.2310.285; p b 0.05). Likewise, the partial correlation between bizarre
experiences and suppression was signicant (r = 0.262, p = 0.024) as
well as the partial correlation between social withdrawal and avoidance
(r = 0.258, p = 0.026).
For the patients with depression, correlations between coping and
depression were weak and similar in magnitude for maladaptive versus
adaptive coping. In nonclinical individuals, we found the expected pos-
itive correlation between maladaptive coping and depression while the
corresponding relationship with adaptive coping was negligible.

4. Discussion

Table 2
Correlations between psychopathology and coping styles, separated for group.
In line with prior studies, depression severity was closely tied to dys-
functional coping across all coping domains tested (Moritz et al., 2016).
Scales MAX MAX MAX MAX Patients with depression scored signicantly higher on maladaptive
adaptive maladaptive avoidance suppression
coping and on avoidance and signicantly lower on adaptive coping rel-
coping coping
ative to both psychosis and nonclinical individuals. Moreover, severity
Psychosis sample
of depression was highly correlated with maladaptive coping. In pa-
CAPE (conventional)
Positive 0.312 0.402 0.447 0.459 tients with psychosis, correlation coefcients between maladaptive
Negative 0.378 0.370 0.432 0.277 and adaptive coping with depression severity exceeded those for
Depression 0.527 0.627 0.473 0.434 other dimensions (see also Westermann and Lincoln, 2011). Corrobo-
CAPE (multidimensional) rating prior ndings highlighting the role of suppression for the patho-
Paranoia 0.384 0.417 0.483 0.431
Bizarre experiences 0.314 0.381 0.387 0.429
genesis of positive symptoms, particularly hallucinations (de
Grandiosity 0.087 0.148 0.176 0.230 Leede-Smith and Barkus, 2013; Jones and Fernyhough, 2008, 2006; Mo-
Hallucinations 0.197+ 0.236 0.269 0.310 ritz et al., 2010; Morrison and Wells, 2003), associations between sup-
Magical thinking 0.207+ 0.266 0.309 0.314 pression and paranoid, rst-rank (bizarre experiences) and positive
Affective attening 0.198+ 0.262 0.327 0.258
symptoms (conventional algorithm) withstood a correction for depres-
Avolition 0.419 0.446 0.407 0.243
Social withdrawal 0.336 0.219+ 0.444 0.277 sion severity. This was not the case, however, for hallucinations and
PHQ-9 0.441 0.594 0.475 0.421 other positive symptoms, which conrms recent attempts to differenti-
ate symptoms within the positive syndrome. As described in the intro-
Depression sample
PHQ-9 0.222 0.241 0.159 0.136 duction, results are in line with the hypothesis that the paradoxical
increase of negative thoughts during suppression increases paranoid
Nonclinical sample
ideas and perhaps also feelings of thought insertion. However, further
PHQ-9 0.053+ 0.511 0.334 0.302
research is needed to pinpoint the specic mechanisms of action.
+
p b 0.1. Our results also accord to prior studies indicating that (experiential)
p b 0.05.
p b 0.01.
avoidance promotes paranoia (Freeman et al., 2005; Moutoussis et al.,
p b 0.005. 2007; Udachina et al., 2014), possibly because avoidance and safety be-
p b 0.001. haviors perpetuate paranoid ideas by preventing their disconrmation
 S. Moritz et al. / Schizophrenia Research 175 (2016) 129135
(Freeman et al., 2002). Avoidance was also correlated with social
withdrawal.
As hypothesized, in nonclinical and individuals with psychosis the
magnitude of the (negative) correlation of adaptive coping with depres-
sion was lower than the (positive) correlation of maladaptive coping
with depression severity. In contrast, for depressed patients no correla-
tional difference was found with respect to the magnitude of the correla-
tion (r = 0.22 for functional coping and r = 0.24 for dysfunctional
coping) which conicts with our forerunner investigation carried out in
a general population sample as well as other studies (Aldao and
Nolen-Hoeksema, 2012b; Aldao et al., 2010). It deserves to be tested
whether the restricted item range on the PHQ-9 (only depressed patients
with mild to moderate depression were investigated) was responsible for
this and/or if research with high-risk samples yields different results than
research with clinical patients (see Introduction section).
4.1. Strengths and limitations
A strength of the study is that we recruited sizable samples and com-
pared psychosis patients with both clinical and nonclinical controls. We
adopted rigorous criteria for screening samples and prior research indi-
cates that online studies yield results comparable and compatible with
clinical research. They can also actively address several shortcomings
of conventional research, for example, the anonymity of the survey fos-
ters open responses. We also consider it a strength that we used a newly
developed coping questionnaire (MAX) encompassing classical as well
as coping and emotion regulation styles that have been the focus of re-
cent research (e.g., acceptance, thought suppression). At the same time,
the self-report nature of the scale is problematic as it necessitates ade-
quate metacognitive awareness about one's coping repertoire. More-
over, the cross-sectional nature of the study does not allow drawing
causal inferences. Furthermore, it would have been advantageous to ad-
minister the CAPE across all populations. Finally, while we provided a
more ne-grained correlational pattern for the different psychotic syn-
dromes and coping styles, depression was tapped by a one-dimensional
scale. As depression involves different aspects such as emotion, drive
and also somatic functions including sleep which may correlate very dif-
ferently with coping styles, it would be advisable to decompose the con-
cept in future work.
4.2. Is coping irrelevant to psychosis?
The present study emphasizes the role of avoidance and (cognitive
and expressive) suppression for the pathogenesis of positive symptoms.
Teaching patients not to engage in (experiential) avoidance by means of
confrontation/reality testing may decrease paranoia and also rst-rank
symptoms. This endeavor is, however, challenging in view of the multi-
fold cognitive biases and disabilities of patients. Imagine a patient with
psychosis with obesity and extrapyramidal symptoms due to antipsy-
chotic side-effects who is not used to engage in social contact. This pa-
tient may attract irritating looks of others which could reinforce
paranoid beliefs of being watched. Reality testing will only lead to
correcting experiences if the scenario is planned and analyzed
thoroughly.
For maladaptive and adaptive coping implications are harder to de-
rive. Notwithstanding that the individuals with schizophrenia scored
better than the depressed patients on these two dimensions and the un-
specic correlation with positive symptoms, it would be premature to
conclude that maladaptive and adaptive coping are irrelevant to the un-
derstanding and treatment of positive symptoms. Although speculative
at this point, the successful treatment of maladaptive and adaptive cop-
ing could exert an effect on positive symptoms via an improvement of
depression. Indeed, longitudinal and experimental studies suggest that
depression plays a prominent role in delusion formation (Freeman
and Fowler, 2009; Hartmann et al., 2014; Myin-Germeys and van Os,
2007) and depression is often viewed a frequent prodromal feature of
133
subsequent psychosis. In their most recent theoretical model, Freeman
and Garety (2014) ascribe six symptoms a prominent role in paranoia
formation, of which three are strongly related to or even represent
core symptoms of depression (worry thinking style, negative beliefs
about the self, sleep disturbance). Some positive symptoms have been
conceptualized as a compensation for low self-esteem and other de-
pressive features. To illustrate, voice-hearing may serve the function of
human surrogate that is actively contemplated by patients, particularly
when the voices are benevolent (Morrison et al., 2004), and some pa-
tients have positive attitudes towards delusional ideas and other posi-
tive symptoms as they impart them with power and purpose (Moritz
et al., in press-a; Sundag et al., 2014). Finally, even the ability to respond
to paranoid thoughts in a functional manner, which is relevant to symp-
tom maintenance, is largely explained by depression (Lincoln et al.,
2014).
Successful treatment of depression in psychosis via decreasing mal-
adaptive and strengthening adaptive coping may therefore with some
delay have a positive impact on the core positive syndrome (Lincoln
et al., 2013). We should also bear in mind that clinicians and patients
often differ in their targets of treatment. Patients often view the treat-
ment of depression, which is present in at least 50% of patients, as
more relevant for treatment than core psychosis symptoms (Byrne
et al., 2010; Kuhnigk et al., 2012; Moritz et al., in press-b). Thus, treat-
ment of depression in schizophrenia may represent a via regia rather
than a detour.
Funding source
The study did not receive any external funding.
Contributors
Steffen Moritz, Joy Hermeneit and Jessica Watroba planned the design. All three au-
thors as well as Tania Lincoln, Stefan Westermann and Thies Ldtke calculated the data
and participated in the write-up of the manuscript.
Conict of interest
None.
Acknowledgement
None.
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