**2.2. The function of coping strategies for psychosis**

Because of this cycle, positive symptoms may occur.

26 Psychosis - Biopsychosocial and Relational Perspectives

*2.1.7. The classification of Kingdon and Turkington for psychosis*

and to use the normalization rationale to explain the symptoms [15].

*2.1.8. The social rank theory of auditory hallucinations*

be summarized as follows:

unresponsive).

or malevolent [33, 36–38].

**A:** hallucinations (activating event),

The symptoms are maintained by *cognitive processes* including reasoning and attributions,

Kingdon and Turkington classify psychosis as a **gradual** or an **acute onset**. They categorize the gradual onset as *sensitivity psychosis* (the patient has predominant negative symptoms and the onset is adolescence) and *trauma-related psychosis* (the patient has a trauma history and the symptoms are very distressing and the content of hallucinations is about abuse). If it is acute onset, then it could be two possibilities: *anxiety psychosis* (as a response of a distressing life event, the patient becomes socially isolated, and he/she attributes their distress to an irrelevant situation actually related to their delusional system with or without hallucinations) or *drug-related psychosis* (the first attack begins with drug use and the following attacks have persisting psychotic symptoms which are the same nature and content of the initial episode). It is important to understand the type of psychosis to establish the engagement with the patient

The social rank theory was generally used for depression and anxiety disorders but considering the parallel mechanisms within the scope of "attack the weaker and submit to the stronger," it was finally modified for hallucinations. Different from other cognitive theories, this theory considers *the patient's relationship with voices as well as with his significant others.* This approach uses the ABC framework. ABC model for auditory hallucinations of psychosis can

**B:** beliefs including automatic thoughts, assumptions, and images about the activating event

**C:** emotional and behavioral consequences (to resist, to cooperate, to attach, and to remain

Activating events can be categorized into three types including symptoms and internal events (e.g., hallucinations), descriptions of interactions with significant others like parents or siblings, and significant life events (diagnosis, hospitalization, and social stigma). According to this theory, the hallucinations demonstrate *a core self-perception of low social rank*, so the person perceives that he/she is in control of his/her parents or peers and community. The emotional consequences of these evaluations can be shame, humiliation, and depression. In this context, the distress and behavior are related to patients' perceived relationship with voices, their appraisal of voices power and omnipotence, as a result they evaluate the voice as benevolent

(this might not be the direct interpretation of the content of hallucination),

dysfunctional schemas, *emotional processes,* and *appraisal of psychosis* [34, 35].

Coping is a personal resource that an individual already possess and uses while trying to deal with an unpleasant stimulus. It comprises some mechanisms related to behavioral actions, as well as cognitive processes. As mentioned earlier, our vulnerability limit determines the stress level that we can handle. So, we can say that coping has a very close relation with vulnerability and resilience terms. Resilience protects the individual from the effects of stress, thus it is functional and adaptive. But coping responses to stress may be adaptive or maladaptive. In fact, psychotic patients often use maladaptive-coping strategies. Cognitive theories also emphasize the role of these maladaptive strategies in the maintenance of psychosis [39]. Due to their important effects, this part includes the coping strategies that the psychotic patients have already used.

In addition, a high expressed emotion term is accepted as an important factor that causes maintenance of the psychosis. The coping strategies of patients' relatives determine the expressed emotion level and style. Thus, this topic is also addressed in this part.
