ORIGINAL PAPER

Katherine Berry Æ Christine Barrowclough Æ Jane Byrne Æ Nitin Purandare

Coping strategies and social support in old age psychosis

Accepted: 21 November 2005 / Published online: 28 January 2006

j Abstract Background According to vulnerability–stress models of psychosis, cognitive and behaviouralcoping strategies can help mediate the potentiallynegative effects of daily stressors. The nature, fre-quency and effectiveness of coping have been studiedin people with psychosis under 65 years of age.However, these findings may not generalise to olderpeople with the diagnosis, as the nature of stressorsand coping strategies may change with increasing age.This study therefore aimed to explore coping in olderpatients with psychosis. Methods A total of 48 olderpatients with psychosis (F20-29, ICD-10) and 25 non-clinical elderly controls were compared using self-report measures of stressors, perceived control overstressors, coping strategies, perceived coping efficacyand social support. A regression analysis was used toexplore predictors of dysfunctional coping in thepatient group. Results Patients used a significantlyhigher proportion of problem-focused coping strate-gies, but they were more dysfunctional copers andrated their coping as less effective compared to con-trols. They also had fewer friends and less emotionalsupport. Severity of symptoms was a significant pre-dictor of dysfunctional coping when depression,cognitive impairment and functional disability werecontrolled. Conclusions Patients with psychosiscoped less well with daily stressors than controls andpatients with more severe symptoms were more dys-functional copers. The findings highlight the potentialbenefit of psychosocial interventions in old age psy-chosis.

j Key words psychosis – schizophrenia – old age –coping – social support

Introduction

According to the vulnerability–stress model, copingstrategies mediate the potentially negative effects ofdaily stressors, thus influencing the course and out-come of psychosis [1]. People with psychosis havebeen shown to use more avoidance or emotion-fo-cused coping, while non-clinical controls use moreproblem-focused strategies aimed at dealing withstressors themselves [2, 3]. In younger samples withpsychosis, patients’ own perceptions of coping effi-cacy has also been shown to be positively correlatedwith frequency of problem-focused coping [3]. How-ever, these findings may not generalise to all stressfulsituations. Lazarus and Folkman’s [4, 5] transactionalmodel of coping suggests that emotion-focused cop-ing may be more functional when nothing can bedone to modify stressors. Stressors in later life, suchas failing vision, hearing and mobility may be lessamenable to change and older people have beenshown to use more emotion-focused coping strategies[6, 7]. Changes in stressors over the life span may alsointeract with changes in psychiatric symptoms andsocial support to influence coping in old age psy-chosis. Although a break down in previous defensemechanisms and coping strategies have been con-ceptualised as a potential triggers for later life psy-chosis [8, 9], there is no published researchspecifically investigating how older adults with psy-chosis cope with the everyday stressors theyencounter in their day to day lives.

The present study therefore aimed to explorecoping strategies in old age psychosis by comparingpatients and non-clinical controls in terms of per-ceived controllability of daily stressors, problem-fo-cused coping, dysfunctional coping, perceptions ofcoping efficacy and social support. It also aimed to

Dr. K. Berry (&) Æ C. Barrowclough Æ J. Byrne Æ N. PurandareSchool of Psychological Sciences, University of ManchesterUnit 4, Ground Floor, Rutherford BuildingManchester Science ParkLloyd Street NorthManchester, M15 6SZ, UKTel.: +44-161/275-8498Fax: +44-161/275-8487E-Mail: katherine.berry@manchester.ac.uk

Soc Psychiatry Psychiatr Epidemiol (2006) 41:280–284 DOI 10.1007/s00127-005-0023-1

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investigate personal and environmental factors cor-related with coping in the patient sample.

Method

j Participants

Patients were over the age of 65 years and recruited from the out-patient clinics or day hospitals of old age psychiatry services inManchester. For inclusion, patients had to satisfy criteria for any ofthe categories F20–29 in the International Classification of Diseases(ICD-10, [10]). Patients were excluded if they had a diagnosis ofdementia, or severe cognitive impairment which affected theirability to complete the study assessments. Controls were elderlyvolunteers who were not known to psychiatry services.

j Assessment of coping

Stress ratings, appraisals of control over stressors, coping strategiesand appraisals of coping efficacy were elicited through a specificallydesigned and piloted semi-structured interview. The measure wasbased on stress and coping assessment schedules used in previousstudies [3, 11], but was adapted to ensure that participants reportedcoping in relation to similar situations, and that measures of stress,control and efficacy were included. Although there are a number ofcoping questionnaires, these have been criticised for failing to cap-ture the complexity of the coping process and have poor reliability[12]. The use of a semi-structured was therefore considered to pro-vide a more valid method of exploring coping strategies.

The interview asked participants about coping in relation tostandard stressors including: difficulties involving other people;declining physical abilities; boredom; crime; and finally any miscel-laneous stressors they identified. Participants were asked if they hadexperienced a difficult or trying situation involving each stressorduring the past month. If they responded positively, they rated on a0–100 visual analogue scale how stressful they found the experience(stress rating), to what extent they believed they could do somethingabout the situation (control rating) and how well they believed theycoped (efficacy rating). Coping strategies were identified by askingparticipants what they said or did to deal with stressors. Responseswere classified as problem-focused if they aimed to change thestressor itself or emotion-focused if they aimed to change emotionalresponses [4, 5]. All strategies reported were categorised by twoindependent raters and a high level of agreement was obtained(kappa = 0.9, SEM = 0.0016, P < 0.001). The difference between eachparticipant’s mean control rating and mean problem-focused copingscore was also calculated to provide a measure of dysfunctionalcoping. High discrepancy scores indicated more dysfunctional cop-ing, as a high proportion of problem-focused coping may be inef-fective if the situation is beyond the individual’s control and is notamenable to change. The test–re-test reliability of the measure wasassessed in a subgroup of participants (n = 10) over a 2 week period,and found to be high for all coping variables (stress rating: r = 0.85,P = 0.002; control rating: r = 0.92, P < 0.001; efficacy rating:r = 0.95, P < 0.001; problem-focused coping: r = 0.79, P = 0.006; anddysfunctional coping: r = 0.84, P = 0.002).

j Assessment of social support and psychopathology

A network interview and emotional and instrumental supportscales were used to measure social support [13]. Severity of illnessin the patient sample was assessed using the Positive and NegativeSyndrome Scale (PANSS; [14]) and high levels of inter-rater reli-ability were maintained throughout the study (all ICC > 0.87). TheGeriatric Depression Scale (GDS; [15]) was used to assess depres-sion in both groups, due to its potential influence in the copingprocess [16].

j Additional measures

The mini mental state examination (MMSE, Folstein et al 1975),which measures global cognitive impairment; the National AdultReading Test (NART; [17]), which measures pre-morbid intelli-gence; the Barthel Index [18], which measures functional disability;and an interview to elicit demographic data were used to describeand compare the samples. Illness-related information was obtainedfrom patients’ medical records.

j Statistical analyses

Data sets were assessed for normality and where possible skewedvariables were transformed. If transformations were unsuccessful,non-parametric equivalents were used. ANCOVAs were used tocontrol potential confounding factors in between group compari-sons, including age, cognitive impairment and depression. Pre-dictors of dysfunctional coping were investigated using bivariatecorrelations followed by a stepwise multiple regression analysis.

Results

j Sample characteristics

The clinical group comprised 48 patients with ICD-10[10] diagnoses of schizophrenia (n = 38), schizoaf-fective disorder (n = 8) and delusional disorder(n = 2). The mean duration of illness was 31 (15.08)years and the mean age of onset was 41.96 (14.49)years. The non-clinical group comprised 25 volun-teers who did not differ significantly from the clinicalgroup on the majority of demographic and clinicalmeasures (Table 1). Patients were, however, signifi-cantly younger and had significantly lower MMSEscores. Although five patients scored 17 or less on theMMSE, which would indicate moderate cognitiveimpairment, they were still included in the mainanalyses, as their low scores related to a refusal toanswer questions and in some cases visual impair-ment [19]. Data were reanalysed excluding these

Table 1 Sample characteristics for clinical and non-clinical groups

Patient group n = 48 (sd) Control group n = 25 (sd) Test statistic (df) P-value

Female (%) 79.2 64 v2 = 1.96 (1) 0.174Mean age 72.71 (5.61) 83.58 (7.19) t = )7.44 (71) 0.001Mean MMSE 24.6 (4.13) 26.33 (2.71) t = )1.86 (66.08) 0.033Mean GDS 8.33 (5.91) 6.72 (5.47) t = 1.14 (71) 0.26Mean NART 91.8 (10.42) 95 (10.49) t = )1.17 (62) 0.245Mean Barthel 91.46 (9.78) 89.6 (10.89) t = 0.74 (71) 0.461

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individuals and similar significance levels were ob-tained despite a reduction in statistical power.

j Coping

Patients and controls were compared on measures ofcoping (Table 2). Both controls and older adults withpsychosis reported experiencing similar levels ofstress. Patients appraised their stressors as signifi-cantly less controllable, but this group difference wasno longer significant when adjusting for depression(F(1,70) = 3.34, P = 0.072) and cognitive impairment(F(1,69) = 2.19, P = 0.143). Patients reported using asignificantly higher proportion of problem-focusedcoping, but perceived their coping as significantlyless effective than controls. Patients were signifi-cantly more dysfunctional in their coping thancontrols, as they had higher discrepancy scores. Inthe majority of cases, both patients (n = 43) andnon-clinical participants (n = 20) had higher prob-lem-focused coping scores than control ratings.Group differences in problem-focused coping, cop-ing efficacy and dysfunctional coping were still sig-nificant when controlling for the age, cognitiveimpairment and depression.

j Social support

Patients and controls were compared on measures ofsocial support (Table 3). Patients were in contact withsignificantly fewer family members, but this groupdifference was no longer significant after adjusting fordepression (F(1,70) = 3.69, P = 0.059). Patients werein contact with significantly fewer friends and re-ported significantly lower levels of emotional supportthan controls, but the groups did not differ in termsof instrumental support.

j Predicting dysfunctional coping

There was a significant positive correlation betweendysfunctional coping and PANSS total scores, sug-gesting that patients with more severe symptomswere more dysfunctional copers (r = 0.567,P < 0.001). There were no significant correlationsbetween dysfunctional coping and social supportmeasures. A hierarchical multiple regression (Ta-ble 4) was carried out to determine whether severityof symptoms predicted dysfunctional coping whendepression, cognitive impairment and functionaldisability were controlled. These control variableswere selected as they had stronger univariate rela-tionships with coping than other study variables. Ashypothesised, PANSS total score accounted for asignificant degree of the variance in coping (R2

change = 0.26, F change = 16.51 (1,43), P < 0.001).Neither duration of illness nor age of onset weresignificantly correlated with dysfunctional coping orany of the other coping or social support variables.

Discussion

Older adults with psychosis reported using a higherproportion of problem-focused coping strategies thancontrols. This finding is in contrast to similar case–control studies in younger patients [2, 3]. As indi-viduals with psychosis age, they may therefore makemore attempts to cope with problems directly ratherthan withdrawing. However, the greater discrepancybetween appraisals of control and proportion ofproblem-focused coping in the patient compared tothe non-clinical sample, suggests that older adultswith psychosis may have difficulties adapting theircoping in accordance with the demands of each sit-uation. Firstly, cognitive deficits, such as impairments

Table 2 Coping measures for clinical and non-clinical groups

Patient group n = 48 (sd) Control group n = 25 (sd) Test statistic (df) P-value

Mean stress rating 0–100 59.83 (18.12) 60.5 (16.65) t = )0.14 (71) 0.886Mean control ratinga 0–100 32.34 (20.61) 43.13 (19.95) t = )2.15 (71) 0.035Mean % of problem-focused coping 63.39 (18.4) 50.21 (17.98) t = 2.90 (71) 0.005Mean dysfunctional coping score 0–100 33.84 (19.07) 13.08 (10.5) t = 5.99 (70.72) <0.001Mean efficacy rating 0–100 50.62 (19.25) 75.19 (20.94) t = )5.02 (71) <0.001

aGroup effect not retained after adjustment for depression and cognitive impairment

Table 3 Network and perceived social support measures for clinical and non-clinical groups

Patient group n = 48 (sd) Control group n = 25 (sd) Test statistic (df) P-value

Mean no. of family membersa 2.21 (2.09) 3.6 (3.7) t = )2.06 (71) 0.043Mean no. of friendsb (range) 1.31 (0–7) 1.58 (0–7) t = )2.77 (71) 0.007Mean emotional support score 2.94 (0.72) 3.4 (0.48) t = )2.92 (71) 0.005Median instrumental support score (range) 3 (0–3) 3 (0–3) z = )0.33 0.739

aGroup effect not retained after adjustment for depressionbLogarithm transformation (geometric mean and range presented)

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in central executive skills may impact on the flexibleuse of problem and emotion-focused coping [20].Secondly, other situational appraisals may interactwith appraisals of control to influence the selection ofcoping strategies. For example, patients may have apreference for problem-focused coping, because theyperceive stressors as more important or threateningthan controls [21]. Thirdly, older adults with psy-chosis may not adapt their coping across situations,due to general beliefs about their inability to influenceoutcomes [22].

As with younger samples with psychosis, patientsreported coping less effectively with stressors thancontrols [3]. Although the extent to which appraisalsof coping efficacy actually correlate with coping out-comes was not assessed in this study, living with se-vere mental health problems that may be exacerbatedby stress is likely to impact on perceptions of one’sability to cope with daily stressors [23].

Consistent with previous research involving olderpeople with psychosis, patients had contact with fewerfriends [24] and less emotional support [25] thancontrols. The reduced friendship networks in thepatient group may suggest that psychiatric symptomscontinue to impair the individual’s capacity to formor maintain social relationships into old age [32].Older adults with psychosis may therefore have lessopportunities to obtain emotional support, which isan important form of emotion-focused coping.

Severity of symptoms was a significant predictor ofdysfunctional coping. Research involving patientswith psychosis under 65 years of age has also shownthat patients who vary their focus of coping inaccordance with appraisals of stressor changeabilityhave lower levels of stress and higher levels of func-tioning [26]. Symptoms may therefore impact on theability to select adaptive coping strategies. It is alsoplausible that more dysfunctional coping leads tohigher levels of symptoms.

The finding that patients were more dysfunctionalcopers than controls and dysfunctional coping wascorrelated with severity of symptoms suggests olderadults with psychosis may potentially benefit frompsychosocial interventions. Although causal infer-ences cannot be drawn from this cross-sectionalstudy, previous research in younger patients hasshown that psychosocial interventions to enhancecoping ability and social support can reduce symp-tom severity and improve overall level of functioning[27]. Previous research has also shown that older

adults with other mental health problems, such asanxiety or depression can benefit from cognitive-behavioural interventions, which include specificcomponents focused on coping with stress andproblem solving (Kodar et al. 1996; [28]). Interven-tions to improve the selection of appropriate copingstrategies may therefore be worth exploring witholder adults with psychosis and may help in movingaway from the current bias towards biologicalexplanations and treatments for mental healthproblems in old age psychosis [29].

The study was limited by the use of conveniencesampling, significant group differences in age andcognitive impairment, the absence of a clinical controlgroup, and the cross-sectional design. Multiple com-parisons were also carried out, thus increasing theprobability of type I error. However, the positivefindings justify the investigation of coping in morerigorously controlled studies with larger samples.

Conclusion

Older adults with psychosis use problem-focusedcoping strategies inappropriately and appraise theircoping as less effective than controls. Severity ofsymptoms is also associated with dysfunctional cop-ing. Furthermore, older adults with psychosis havereduced social networks and emotional support,which are important in terms of coping with the rel-atively uncontrollable stressors that people mayencounter in old age.

j Acknowledgements We thank study participants, Julie Morrisfor her statistical advice, Katherine Eastham and Virginia Bell fortheir assistance in the reliability analyses and Catherine Stewart andLisa Marie Aitken for their assistance in patient recruitment.

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