Interaction of social role functioning and coping in people with recent-onset attenuated psychotic symptoms: a case study of three Chinese women at clinical high risk for psychosis

Introduction

Although it is well known that there is a strong genetic or biological underpinning to psychosis,¹ the role of social factors in the development of psychosis has perhaps been underestimated in clinical practice and research. Clinicians and scientists in the People’s Republic of China may overemphasize the question, “What has changed in the brain of a psychotic patient?”, and they do not often ask, “How do changes in the patient’s social world affect the brain and behavior of a psychotic patient?” In addition, it is difficult to explore underlying problems, such as the interaction between psychotic symptoms and the social role functioning and coping, through quantitative studies that use questionnaires or cross-sectional interviews.

A recent development in psychiatry has the potential to provide a more complete and in-depth understanding of the development of psychotic disorder. The concept of a prodromal stage of psychosis, or clinical high risk (CHR) syndrome, has evolved over the last 20 years.^2–6 According to follow-up studies, the CHR transition rate within a year of the first manifestation of symptoms averages approximately 20% and increases to around 35% within 3 years.^3,7–9 Thus, nearly two-thirds of those at CHR may not develop psychosis, at least within a relatively short time span. Biomarkers may ultimately help to identify individuals who are likely to progress to full psychosis, but each individual’s unique background may also contribute to outcomes other than the onset of psychotic symptoms.

We present the cases of three Chinese female subjects of different ages and backgrounds who fulfilled the criteria for attenuated positive symptom or syndrome (APSS), one of the CHR syndromes. We collected information on symptoms and life stressors every 2 months for 6 months. We examined these cases to understand the more detailed processes by which the individuals deal with APSS in their everyday lives.

Case reports

Three cases were selected from a broader research study¹⁰ of CHR in a Chinese clinical population conducted in 2012. This study was approved by the Research Ethics Committee at the Shanghai Mental Health Center. All three subjects were identified via screening with the Prodromal Questionnaire-Brief version¹¹ and met the APSS criteria in the Structured Interview for Prodromal Syndromes.¹² Subjects returned for follow-up appointments every 2 months to discuss the development of psychosis as well as problems faced in their social lives.

Background

The subjects included one younger (15 years; Case A) and one older teenager (18 years; Case B) and a young adult (35 years; Case C), each from a typical Chinese household. The recent onset of attenuated psychotic symptoms precipitated a drastic change in their normal lives and social roles. Thus, it was with significant uncertainty and desire that these individuals sought help in a psychological-counseling setting at the Shanghai Mental Health Center (in the People’s Republic of China, this setting is associated with less stigma than psychiatric settings). They attended counseling sessions with various kinds of pressure from their families, schools, and workplaces – and from society in general. The subjects had similarly poor interpersonal skills and limited social support outside their families. Their personality traits, family situations, life experiences, and social activities were quite diverse, but none had a prior history of medication use, psychological treatment, hospitalization, serious physical problems, substance abuse (drug or alcohol), or mental disorders within the family (Table 1).

Table 1 Background information on the CHR subjects Note: Diagnostic and treatment information were obtained from clinicians’ routine medical records. Abbreviation: CHR, clinical high risk.

Baseline attenuated psychotic symptoms

All three women experienced unusual ideas and perceptions. Each woman described her symptoms differently, in a way that was consistent with her background. For example, Case A was very fond of mystery and suspense stories, and she attributed her hallucinations to supernatural forces. Case B experienced sudden auditory hallucinations, and, consistent with her college background, tended to explain the voices in scientific ways (eg, being implanted with a mind-reading device). Case C had experienced a greater number of changes and hardships than the other subjects. One significant stressor was a recent divorce, which is still a widespread cause for discrimination in Asian societies. Her suspiciousness was primarily related to her divorce. These cases illustrate how psychotic symptoms might reflect individual experiences and environments (Table 2).

Table 2 Attenuated positive psychotic symptoms identified in the baseline interview Notes: P, positive symptoms (scales P1–P5, Unusual Thought Content, Suspiciousness, Grandiosity, Perceptual Abnormalities, and Disorganized Communication). Each item is rated on a 0–6 scale with 6 indicating “severe and psychotic” and 3–5 indicating a prodromal range symptom. Abbreviations: APSS, attenuated positive symptom or syndrome; SIPS, Structured Interview for Prodromal Syndromes.

Follow-up

Although 6 months is a relatively short period in the course of a potential psychotic disorder, it is a critical period from the perspective of illness development. The women described here were struggling in their daily lives and suffering with the recent onset of symptoms in different ways. Their social role and daily functioning had declined to varying degrees. They were often excluded from the social groups to which they had previously belonged. In addition, these cases suggest that the older the person is at symptom onset, the greater the difficulties he or she may face in certain social contexts. One potential reason may be that unusual thoughts may be more acceptable in younger than older people because the young are thought to be more imaginative. Thus, society may be more tolerant of certain symptoms in teenagers than in college students or adults (Table 3).

Table 3 Changes in CHR subjects during the 6-month assessment period Abbreviations: CHR, clinical high risk; OCD, obsessive–compulsive disorder.

Summary

Figure 1 shows the course of the women’s psychotic symptoms over the 6-month period. Although they seem to follow different trajectories in the early stage of psychosis, it is obvious that medical help may have had some effect on their symptoms. The social functioning of Cases A and C synchronized with the severity of their symptoms. Social inclusion of subjects with recent-onset psychosis may be crucial, especially for the recovery of their social role functioning. Sadly, social exclusion was a large part of each of these women’s experiences during the initial period after symptom onset.

Figure 1 Trajectory of psychotic symptoms and social functioning in the early stage of psychosis. Notes: ---, level of social functioning; —, level of symptoms. Cases A–C follow different trajectories during the course of the women’s psychotic symptoms over the 6 month period. The social functioning and severity of psychotic symptoms were impacted by family support, medication, social inclusion, or social exclusion. Social inclusion may be crucial for prodromal stage of psychosis, especially for the recovery of their social role functioning.

Discussion

We described three cases with recent-onset psychotic symptoms in individuals who appeared at first to be insightful and eager for help. Each struggled with severe pressures in their daily lives. Psychosis has attracted considerable attention in clinical settings in the People’s Republic of China; it is not surprising that all three subjects had been prescribed antipsychotic medication by our clinicians, none of whom had much experience with the concept of “CHR”. Although there is still considerable debate regarding ethical issues with the use of medication in the prodromal stage,^13,14 medication in these three cases resulted in some improvements. However, the way the women balanced their real-world responsibilities and their psychotic symptoms was quite varied. Moreover, the effectiveness of and compliance with treatment did not appear to rely on a particular (or “just right”) medicine.

Insight during the early stages of psychosis has been associated with better outcomes.^15,16 Yet the quality of insight should be carefully considered and nurtured.^17,18 Individuals with mental illness have limited resources and capability to openly express and manage their confusion about their psychotic symptoms. In the cases presented in this paper, family members were the first resources from whom the women could seek help. After family, professional but less stigmatized institutions were their second preferred option. Services¹⁹ that help individuals interact with society are urgently needed. This reality-based interaction may be particularly important to help CHR individuals build insights into the psychotic nature of their symptoms.

The three women with CHR in this study might have been capable of handling their roles as patients, daughters, or family members, but they had difficulty fulfilling their larger society roles. When faced with greater responsibility outside their immediate support network, they all followed a similar coping style that included hiding their symptoms from others in their school or workplace. Given the very high stigma associated with psychosis in the People’s Republic of China, one might think it advisable to avoid exposing psychotic patients to others. However, concealing all feelings and thoughts about psychotic experiences might lead to erroneous judgments of others’ thoughts and interfere with insights about the psychosis. It could also create internal conflicts about their experience and how others perceive them.²⁰

None of the cases reported here were treated by a professional clinician skilled at psychotherapy or psychosocial therapy. Generally, Chinese clinicians have a bias to treat psychotic symptoms only with medication. Although the current literature^21–23 on interventions at the prodromal stage does not adequately address what kind of therapy would be appropriate in Chinese society, it is universally agreed upon that some type of treatment for the CHR population is warranted. Given that daily functioning and the overall quality of life for CHR individuals is severely affected by psychotic symptoms,²⁴ and that these symptoms are often “cognitive” in nature, a cognitive therapy²⁵ that focuses on either clinical symptoms or interpersonal functioning should be implemented. In addition, alternative treatments or adaptations that are sensitive to Chinese culture may be needed. Moreover, since the three individuals in this study all sought help from their families, psycho-education for families is essential and may be especially helpful in the People’s Republic of China.

We offer two suggestions for dealing with the social exclusion of CHR individuals. First, an intervention center that provides early psychosis services targeted toward CHR individuals should be established. These services could be provided by a team of psychologists, psychiatrists, volunteers, and “non-converters” (peers who had previously experienced psychotic symptoms but no longer meet the CHR criteria). The center could then act as a cushion between the pressure experienced from psychotic symptoms and social exclusion. Second, in order to minimize the risk of progression to psychosis, clinicians and family members might consider insight-oriented supportive education²⁶ for CHR persons, rather than focusing only on the effectiveness of medication or the individual’s performance at school or at work.

Overall, a lack of social activities in CHR individuals may be a risk factor in the development of psychosis and a mediator of functional sequelae in psychosis. Since it may not be feasible for CHR persons in the People’s Republic of China to disclose their psychotic symptoms to colleagues or classmates, therapy that supports greater insights into symptoms or service that provides a forum in which those with CHR can discuss their psychotic symptoms may help these individuals overcome their difficulties.

Acknowledgments

This study was supported by National Natural Science Foundation of China (81201043, 81171267, 81171280, 81261120410, and 81361120403), Shanghai Municipal Natural Science Foundation (12ZR1448400), Shanghai Science and Technology Committee (15411967200), National Key Clinical Disciplines at Shanghai Mental Health Center (Office of Medical Affairs, Ministry of Health, 2011-873; OMA-MH, 2011-873), Shanghai Key Laboratory of Psychotic Disorders (13dz2260500), Doctoral Innovation Fund Projects from Shanghai Jiao Tong University School of Medicine (BXJ 201345), Shanghai Jiao Tong University Foundation (14JCRY04 and YG2014MS40), and by a Fogarty and National Institutes of Mental Health grant (1R21 MH093294-01A1) from the USA. The authors wish to thank the participants and study team in Shanghai.

Disclosure

The authors report no conflicts of interest in this work.

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