*2.1.1. Vulnerability-stress model of psychosis*

getting any support or treatment [3–5]. In community, every one person of four reports at least one psychotic-like experience [3]. The rate of psychotic experiences that cause seeking

The persons who are confronted with anomalous experiences and do not need to seek help are the ones who generally do not overevaluate these kinds of experiences. On the other hand, the persons who develop psychosis in the end are more anxious about and more preoccupied with their beliefs and experiences. The person searches for a meaning of this anomalous experiences and the coping process with severe anxiety lead delusions and voices [7, 8]. In addition, maladaptive-coping strategies such as avoidance or safety behaviors play a particularly

In this chapter, we initially review the vulnerability-stress models and the other cognitivebehavioral explanations to psychosis. These explanations will be stated as "coping-related explanations" in the text, because they often emphasize the coping process with the anomalous experience or the interactions between internal (e.g., deprivation in self-monitoring process) and external (e.g., environment, trauma) factors. With the help of these explanations, we try to understand the development of psychotic symptoms as a continuity of normality. Then, we handle the role of maladaptive-coping strategies in the maintenance of psychotic experiences. Patients' relatives' coping strategies will also be taken into consideration due to their role in the maintenance of psychosis. We finally address the importance of developing and enhancing adaptive-coping strategies and changing irrational thinking for challenging

psychosis. We also emphasize the role of social support in every stage of psychosis.

vulnerability to resilience and regress from resilience to vulnerability.

We can conceptualize both vulnerability and resilience terms with the help of similar explanations or factors. In other words, factors that enhance or reduce resilience are similar. Resilience means the ability to protect the mental health. The sources of resilience may be psychological (personal traits, interpretation of events, etc.), biological (brain structure, genetic factors), or environmental (family interactions, community factors, etc.). Thanks to these adequate sources, the individual can cope with stressful events. On the other hand, lack of these adequate sources makes the person more vulnerable in the struggle of life. In addition, the sources of resilience can be weakened because of several factors (stressful life events, deprivation in brain structure, misinterpretations of events, etc.); thus, even a resilient person may also be more vulnerable and develop a mental illness. The terms of vulnerability and resilience should be thought in a continuum, and thus it is both possible to proceed from

Coping-related explanations for psychosis include vulnerability-stress model of psychosis and several cognitive-behavioral explanations. These explanations often emphasize the

treatment ranges from 3 to 8% [2, 3, 6].

22 Psychosis - Biopsychosocial and Relational Perspectives

**2. From vulnerability to resilience**

**2.1. Coping-related explanations for psychosis**

important role in the maintenance of the psychotic symptoms.

Vulnerability-stress model integrates the overall explanations—biological, psychological, and social factors—to explain the structure of psychosis [1, 9–14]. The vulnerability to severe illnesses can arise due to genetic predisposition, birth trauma, brain injury, viruses, and early childhood traumas like physical and interpersonal deprivations [1]. It can be said that a person who has been influenced by one or more of these factors is more vulnerable to develop a mental illness than the others who do not have such a past.

But vulnerability only defines the possibility of developing a psychiatric illness while facing stress. We all have different psychological structure and social environment, and accordingly, the stress level that we each can endure is different. Some of us have significant heritability for the psychotic disorders and the others have not [15]. For instance, the family history of psychosis can indicate the high vulnerability. The more vulnerable person is, the less stress is required for the occurrence of psychosis. According to Zubin and Spring's concept of vulnerability-stress diathesis, so long as the stress stays below the threshold of vulnerability, the individual can cope with events, but whether the stress surpasses the limit, he/she can develop a psychotic episode [16].

## *2.1.2. Beck's theory for delusions*

The use of cognitive-behavioral theory (CBT) for psychosis is originated from Beck's theory of emotional disorders [15, 17]. Nearly 60 years ago, Beck has started to investigate the delusional system of a paranoid patient who believed that he was being watched by the members of a military unit who were working on behalf of the FBI. At the end of a 30-session treatment process, the patient recognized that his delusions were related to his own beliefs (e.g., "I am responsible of my daddy's unfavorable behaviors" and "I'm supposed to be punished due to my weaknesses") and impressed guilty in a schematic level [14, 17]. Thus, cognitive therapy was first shown as helpful for the treatment of psychotic patients [17–19].

Then, this success was supported by another case study [17]. Hole et al. [20] defined four dimensions for measuring delusions as a result of their hour-long interviews with delusional inpatients: *conviction, accommodation* (the degree to which a delusion could be modified by external events), *pervasiveness* (the percentage of the day spent ruminating about delusions), and *encapsulation* (the extent to which a decrease in pervasiveness could occur without any decrease of conviction). They decided that delusions may function as the other beliefs and may differ from them only quantitatively regarding how they can be influenced by external events [16, 20].

In his subsequent studies, Beck stated that the psychotic patients (particularly paranoids) concentrate especially on monitoring external—including social—sources on the purpose of recognizing the potential danger. Because of being alert all the time for the potential danger, they misinterpret threat when there is none, and they suspect hostiles when there are none. This situation can be described as *externalizing bias*, the attribution of difficulties or internal events to external stimulus. They also have *internal bias*; this is the conviction that the attitudes and the feelings of others toward them cause the events. He also mentioned the *cognitive distortions* of schizophrenia. He emphasized that self-referential or persecutory content of their thoughts often cause anxiety, and sometimes sadness or depression. These distortions include *catastrophizing*, *thinking out of context* (the component of selective abstraction, overgeneralization, dichotomous thinking, jumping into conclusions), *inadequate cognitive processing*, and *categorical thinking* [17].

symptoms (hallucinations/delusions) can occur. The experience of hallucinations and delusions has short-term and long-term results. Short-term results may be on emotional (anxiety, fear, anger), behavioral (belief-parallel behavior, testing the interpretations), cognitive (misinterpretation, attention to perceived threat, selective attribution), or coping basis, whereas long-term results include social withdrawal and isolation, loneliness, decreasing opportunities for reward, and social skill deficits. These results also cause maintenance of the illness [28].

From Vulnerability to Resilience: A Coping Related Approach to Psychosis

http://dx.doi.org/10.5772/intechopen.78385

25

The psychosis model of Morrison resembles Clark's cognitive model for panic. According to this model, the auditory hallucinations are intrusive thoughts which are externally attributed. These intrusive thoughts can be accepted as normal, but the person especially focuses his attention on these intrusions and the distress occurs when the person misunderstands and misinterprets these thoughts like "dangerous." So, this is not the intrusion, but *the interpretation*

The interpretation is the searching for a meaning of this experience. Its meaning depends on the interpretations of the person who heard voices whether he says, "devil is talking to me" or "this is a strange sensation, I think I am too tired" [16, 31]. The first interpretation may increase the person's distress, anxiety level, and lead the other negative emotional consequences. The person tries to find a way to cope with symptoms through maladaptive responses such as avoidance. These emotional consequences and maladaptive responses cause maintaining the

In fact, these are all internal experiences. Furthermore, the cycle between intrusions, interpretations of intrusions as voices, mood, body sensations, and behaviors are parallel with the

This model involves the combination of important factors in developing and maintaining the psychosis. The principal factors are vulnerability, stress, social environment, emotional

The authors emphasize the continuity of psychotic and nonpsychotic experiences. They suggest that *bio-psycho-social vulnerability* (it also includes cognitive and emotional vulnerability)

They state that the interaction of vulnerability and social environment may cause some emotional changes. *Emotional changes* may include depression, anxiety, or low self-esteem.

They consider *cognitive dysfunction* very important because it can lead to anomalous experiences. Emotional changes and cognitive dysfunctions including reasoning biases lead the

*The appraisal of this experience as external* is influenced by reasoning and attributional biases,

can be triggered by the effects of the *social environment*, including stress and trauma.

dysfunctional schemas of self and world, isolation, and adverse environments.

idea that internal experiences are attributed to the external sources [29, 32, 33].

changes, cognitive dysfunction, and appraisal of the experience as external.

*2.1.5. Morrison's explanations for psychosis*

which causes distress and disability [29, 30].

*2.1.6. The model of Garety and colleagues for psychosis*

person to evaluate the experience as external.

symptoms [29, 30].

Beck's cognitive model suggests that genetic and experiential factors interact with *distorted internal representations* (patients' negative appraisal such as "me vs. them") which comprise *the physical and cognitive vulnerability* to psychosis. These representations are important factors which make patient vulnerable to a mental illness. Under acute and prolonged stress, these negative representations start to affect the information-process system and inhibit the patients' ability of reality testing [21].

#### *2.1.3. The neurocognitive explanations of psychosis*

According to Frith Model that explains the cognitive component of schizophrenia, there is *a deprivation in main self-monitoring process* of schizophrenic patients. Thus, they cannot differentiate the situation which results from their own actions and the external ones, so they attribute the internals to the external ones [1, 16, 21–25]. There is also *a lack of awareness of intended actions* in schizophrenic patients; this impairment might affect the sense of will and they can become isolated from their thoughts and actions [22].

Auditory hallucinations of schizophrenia are accepted to be caused by their own inner speech [22]. When the brains of people who reported hearing voices were scanned, many of the same areas of the brain were found to be active during both auditory hallucinations and inner speech [24, 26]. The psychotic patients also reported someone speaking while they were speaking. So, they tend to attribute their own voice to another person [22].

These processes would result in the attribution of internal voices or thoughts to external voices and one's own movement and speech to external causes. These misinterpretations are concluded with auditory hallucinations or thought blocking, and passivity or delusion of control, respectively [1, 16, 21–25].

#### *2.1.4. A heuristic model*

In a heuristic model of the determinants of positive psychotic symptoms, a psychotic experience is suggested as a response to a combination of internal (*inherent biological*: genetic heritability, *acquired biological*: birth trauma, *inherent psychological*: cognitive deficits, *acquired psychological*: cognitive biases, schemata) and external factors (stressors). It is stated that these factors operate via a mediating pathway (e.g., a dysfunction in the arousal system and its regulation) [27]. Consequently, the psychotic experience or persistent positive psychotic symptoms (hallucinations/delusions) can occur. The experience of hallucinations and delusions has short-term and long-term results. Short-term results may be on emotional (anxiety, fear, anger), behavioral (belief-parallel behavior, testing the interpretations), cognitive (misinterpretation, attention to perceived threat, selective attribution), or coping basis, whereas long-term results include social withdrawal and isolation, loneliness, decreasing opportunities for reward, and social skill deficits. These results also cause maintenance of the illness [28].

### *2.1.5. Morrison's explanations for psychosis*

recognizing the potential danger. Because of being alert all the time for the potential danger, they misinterpret threat when there is none, and they suspect hostiles when there are none. This situation can be described as *externalizing bias*, the attribution of difficulties or internal events to external stimulus. They also have *internal bias*; this is the conviction that the attitudes and the feelings of others toward them cause the events. He also mentioned the *cognitive distortions* of schizophrenia. He emphasized that self-referential or persecutory content of their thoughts often cause anxiety, and sometimes sadness or depression. These distortions include *catastrophizing*, *thinking out of context* (the component of selective abstraction, overgeneralization, dichotomous thinking, jumping into conclusions), *inadequate cognitive processing*,

Beck's cognitive model suggests that genetic and experiential factors interact with *distorted internal representations* (patients' negative appraisal such as "me vs. them") which comprise *the physical and cognitive vulnerability* to psychosis. These representations are important factors which make patient vulnerable to a mental illness. Under acute and prolonged stress, these negative representations start to affect the information-process system and inhibit the

According to Frith Model that explains the cognitive component of schizophrenia, there is *a deprivation in main self-monitoring process* of schizophrenic patients. Thus, they cannot differentiate the situation which results from their own actions and the external ones, so they attribute the internals to the external ones [1, 16, 21–25]. There is also *a lack of awareness of intended actions* in schizophrenic patients; this impairment might affect the sense of will and

Auditory hallucinations of schizophrenia are accepted to be caused by their own inner speech [22]. When the brains of people who reported hearing voices were scanned, many of the same areas of the brain were found to be active during both auditory hallucinations and inner speech [24, 26]. The psychotic patients also reported someone speaking while they were

These processes would result in the attribution of internal voices or thoughts to external voices and one's own movement and speech to external causes. These misinterpretations are concluded with auditory hallucinations or thought blocking, and passivity or delusion of

In a heuristic model of the determinants of positive psychotic symptoms, a psychotic experience is suggested as a response to a combination of internal (*inherent biological*: genetic heritability, *acquired biological*: birth trauma, *inherent psychological*: cognitive deficits, *acquired psychological*: cognitive biases, schemata) and external factors (stressors). It is stated that these factors operate via a mediating pathway (e.g., a dysfunction in the arousal system and its regulation) [27]. Consequently, the psychotic experience or persistent positive psychotic

and *categorical thinking* [17].

patients' ability of reality testing [21].

24 Psychosis - Biopsychosocial and Relational Perspectives

control, respectively [1, 16, 21–25].

*2.1.4. A heuristic model*

*2.1.3. The neurocognitive explanations of psychosis*

they can become isolated from their thoughts and actions [22].

speaking. So, they tend to attribute their own voice to another person [22].

The psychosis model of Morrison resembles Clark's cognitive model for panic. According to this model, the auditory hallucinations are intrusive thoughts which are externally attributed. These intrusive thoughts can be accepted as normal, but the person especially focuses his attention on these intrusions and the distress occurs when the person misunderstands and misinterprets these thoughts like "dangerous." So, this is not the intrusion, but *the interpretation* which causes distress and disability [29, 30].

The interpretation is the searching for a meaning of this experience. Its meaning depends on the interpretations of the person who heard voices whether he says, "devil is talking to me" or "this is a strange sensation, I think I am too tired" [16, 31]. The first interpretation may increase the person's distress, anxiety level, and lead the other negative emotional consequences. The person tries to find a way to cope with symptoms through maladaptive responses such as avoidance. These emotional consequences and maladaptive responses cause maintaining the symptoms [29, 30].

In fact, these are all internal experiences. Furthermore, the cycle between intrusions, interpretations of intrusions as voices, mood, body sensations, and behaviors are parallel with the idea that internal experiences are attributed to the external sources [29, 32, 33].

#### *2.1.6. The model of Garety and colleagues for psychosis*

This model involves the combination of important factors in developing and maintaining the psychosis. The principal factors are vulnerability, stress, social environment, emotional changes, cognitive dysfunction, and appraisal of the experience as external.

The authors emphasize the continuity of psychotic and nonpsychotic experiences. They suggest that *bio-psycho-social vulnerability* (it also includes cognitive and emotional vulnerability) can be triggered by the effects of the *social environment*, including stress and trauma.

They state that the interaction of vulnerability and social environment may cause some emotional changes. *Emotional changes* may include depression, anxiety, or low self-esteem.

They consider *cognitive dysfunction* very important because it can lead to anomalous experiences. Emotional changes and cognitive dysfunctions including reasoning biases lead the person to evaluate the experience as external.

*The appraisal of this experience as external* is influenced by reasoning and attributional biases, dysfunctional schemas of self and world, isolation, and adverse environments.

Because of this cycle, positive symptoms may occur.

The symptoms are maintained by *cognitive processes* including reasoning and attributions, dysfunctional schemas, *emotional processes,* and *appraisal of psychosis* [34, 35].

The explanations mentioned earlier would help to understand the occurrence of psychotic episodes. The following passages will also address the maintenance of these psychotic

From Vulnerability to Resilience: A Coping Related Approach to Psychosis

http://dx.doi.org/10.5772/intechopen.78385

27

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

Three types of psychological reaction to psychosis are suggested: *denial and lack of awareness, passive acceptance of the role of patient, acceptance of psychotic illness, and compliance to the treatment*. Neither the first one nor the second are functional because they both inhibit the treatment. The person who does not have awareness refuses the help because he/she does not believe that he/she has an illness and may gradually become more disorganized and dangerous to himself/herself and others. The second one, who passively accepts the sick role, probably abandons to try and ever loses his/her self-esteem. He/she can also develop other clinical problems, depression, and suicidal ideas. Inversely, the last one believes that he/she can learn to cope with his/her symptoms, takes medication, and is motivated to psychotherapy and can

According to patients' description of coping strategies with auditory hallucinations, three phases were described: startling phase in which the patients felt fear, anxiety, and desire to escape in the beginning, then investigated the meaning of voices, and do not try to escape anymore; organization phase in which many patients try to communicate with the voices; and the stabilization phase in which they start to accept the voices as part of themselves

Researches about coping and psychosis show that patients generally use maladaptive-coping strategies, for example, excessive avoidance and safety behavior [41, 42]. Patients with delusions, especially persecutory delusions, often use safety behaviors to decrease the risk of danger. For this reason, they can use a number of rituals such as making hand movement or

expressed emotion level and style. Thus, this topic is also addressed in this part.

symptoms.

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

*2.2.1. The psychotic patients' own coping strategies*

adopt the sick role when necessary [1].

[40].

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

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