Schizophrenia Research 60 (2003) 271 – 283
www.elsevier.com/locate/schres
Emotional responses to psychosocial stress in schizophrenia:
the role of individual differences in affective traits and coping
William P. Horan a,*, Jack J. Blanchard b,1
a
Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, 300 Medical Plaza, Rm. 2255,
Los Angeles, CA 90024-6968, USA
b
Department of Psychology, University of Maryland, College Park, MD 20742-4411, USA
Received 15 November 2001; received in revised form 15 February 2002; accepted 22 February 2002
Abstract
Despite the well-established association between psychosocial stress and symptom exacerbation in schizophrenia, factors
that account for variability in stress reactivity among individuals with this disorder are unknown. This study examined the
association between affective traits, coping style, and neurocognitive functioning and subjective emotional responses during
putatively stressful social interactions among individuals with schizophrenia. Self-reported mood was assessed in male
schizophrenia outpatients (n = 36) and matched nonpsychiatric controls (n = 15) during a role-play test (RPT) comprised of
simulated social encounters requiring assertive or affiliative skills. During the RPT, schizophrenia patients and controls reported
similar elevations in negative mood and decreases in positive mood as compared to baseline mood during assertion scenes.
Affiliation scenes resulted only in similar decreases in positive mood across groups as compared to baseline mood. Among
schizophrenia patients, trait negative affectivity (NA) and maladaptive coping style accounted for one quarter of the variance in
negative mood during the assertion RPTs, and these relationships held after controlling for baseline mood, clinical symptoms,
and neurocognitive functioning. Results provide preliminary support for the validity of the social RPT as a paradigm for
examining psychosocial stress in schizophrenia and suggest that trait negative affectivity and maladaptive coping are associated
with individual differences in emotional responses to psychosocial stressors in schizophrenia.
D 2002 Elsevier Science B.V. All rights reserved.
Keywords: Schizophrenia; Stress; Personality traits; Coping; Emotion
1. Psychosocial stress reactivity in schizophrenia:
the role of individual differences in affective traits
and coping
Vulnerability – stress models of schizophrenia hypothesize that dispositional vulnerability factors are asso*
Corresponding author. Tel.: +1-310-206-8181; fax: +1-310206-3651.
E-mail addresses: [email protected] (W.P. Horan),
[email protected] (J.J. Blanchard).
1
Also corresponding author.
ciated with sensitivity to environmental stressors that
increase an individual’s liability for the onset or
exacerbation of psychotic symptoms (e.g., Nuechterlein and Dawson, 1986; Nuechterlein et al., 1992).
Stressors that are psychosocial in nature appear to be
particularly important influences on the course of
schizophrenia as evidenced by frequently reported
findings that exposure to adverse life events (e.g.,
Norman and Malla, 1993; Ventura et al., 1989, 1992)
or environments characterized by high expressed emotion (EE; see Butzlaff and Hooley, 1998 for a review)
0920-9964/02/$ - see front matter D 2002 Elsevier Science B.V. All rights reserved.
doi:10.1016/S0920-9964(02)00227-X
272
W.P. Horan, J.J. Blanchard / Schizophrenia Research 60 (2003) 271–283
are associated with exacerbation of psychotic symptoms. Despite this corpus of evidence, current understanding of the psychosocial stress – symptom
exacerbation relationship is limited in two critical
respects. First, the mechanisms through which exposure to stressors may result in symptom exacerbations
are unknown. Second, it is clear that there is considerable variability across individuals with schizophrenia
in terms of susceptibility to stress-induced relapse. For
example, most patients who relapse do not experience
a major life event or return to a high EE environment,
and many do not relapse when exposed to such
stressors (e.g., Kavanaugh, 1992; Ventura et al.,
1989). Although this variability suggests the existence
of key stress modulating factors among individuals
with schizophrenia, patient characteristics that account
for such differences have received minimal attention.
One promising approach to identifying mechanisms involved in the triggering effects of stressors
in schizophrenia is to examine subjectively experienced emotional responses. In a discussion of the
potential role of emotional arousal associated with
exposure to stressful life events, Leff (1994, p. 134)
noted, ‘‘Presumably, the psychological impact of a life
event is due to the evocation of a mixture of powerful
emotions which have to be processed in a short time’’.
Although schizophrenia is not typically conceptualized as an ‘‘emotional’’ disorder, several lines of
evidence indicate that many individuals with schizophrenia are highly emotionally responsive to affectively laden stimuli or events. For example, in
laboratory studies, individuals with schizophrenia
demonstrate heightened sensitivity to negative
affect-inducing stimuli (e.g., emotional film clips;
see Kring, 1999). Additionally, the induction of negative mood (i.e., relatively transient, subjectively
experienced emotional states) is associated with exacerbation of various clinical features of this disorder,
including thought and language disturbances (Docherty, 1996; Rosenfarb et al., 1995), social skill deficits
(Bellack et al., 1992; Mueser et al., 1993), and
autonomic arousal (Tarrier et al., 1988).
Regarding the course of schizophrenia-related disorders, schizophrenia patients have been found to
experience elevations in negative mood (Subotnik
and Nuechterlein, 1988; Tarrier et al., 1991) and
autonomic arousal (Hazlett et al., 1997) prior to
symptom exacerbations. Naturalistic studies using
experience sampling methods indicate that as compared to controls, individuals with psychotic disorders
demonstrate heightened emotional reactivity to naturally occurring daily stressors characterized by larger
increases in negative mood and decreases in positive
mood (Myin-Germeys et al., 2000, 2001). Furthermore, family members of individuals with psychotic
disorders have been shown to demonstrate a similar,
though less pronounced, pattern of negative mood
reactivity to naturally occurring daily stressors, which
is consistent with the possibility that heightened emotional reactivity to stress may be a vulnerability
marker for psychotic illness (Myin-Germeys et al.,
2001). It is noteworthy that elevations in negative
mood are closely linked to activation of the hypothalamic –pituitary –adrenal (HPA) axis (Buchanan et
al., 1999; Smyth et al., 1998; van Eck et al., 1996), a
stress-sensitive neurobiological system that has been
proposed to play an important mediating role in the
stress – symptom exacerbation relationship in schizophrenia (Walker and Diforio, 1997). Thus, subjective
emotional responses may play a key role in the
process through which exposure to stress results in
symptom exacerbations.
As noted above, important modulating variables
are likely to contribute to the heterogeneity in stress
reactivity observed among individuals with schizophrenia. To date, success in identifying patient characteristics that account for this heterogeneity has been
limited. Basic demographic characteristics such as
gender, age, and number of previous hospitalizations
do not appear to be important moderators (Norman
and Malla, 1994; Pallanti et al., 1997), and clinical
symptom state contributes only modestly to variability
in stress reactivity (e.g., Norman and Malla, 1994;
Pallanti et al., 1997). An alternative approach to
identifying such factors in schizophrenia is to examine
enduring psychological characteristics that may
increase or decrease vulnerability to stress. For example, certain personality traits and coping styles have
proven to be robust moderators of stress reactivity in a
variety of clinical and nonclinical populations (for
reviews see Clark and Watson, 1999; Skodol, 1998;
Taylor and Aspinwall, 1996). While such factors have
been theorized to be relevant for understanding stress
reactivity in schizophrenia (e.g., negative affectivity;
Fowles, 1992), they have received limited research
attention.
W.P. Horan, J.J. Blanchard / Schizophrenia Research 60 (2003) 271–283
Research indicates that many individuals with
schizophrenia are characterized by a pattern of personality traits and coping style that may amplify the
effects of psychosocial stressors. Regarding personality traits, schizophrenia has repeatedly been associated with elevated trait negative affectivity (NA) and
low trait positive affectivity (PA) as compared to
normal controls (Berenbaum and Fujita, 1994; Blanchard et al., 1998), a pattern that appears to be stable
across different clinical states (Blanchard et al., 2001).
Trait NA refers to an enduring disposition to experience intense aversive emotional states, increased likelihood to experience distress or dissatisfaction at all
times, and heightened sensitivity to environmental
stressors (Watson and Clark, 1984, 1996). In contrast,
trait PA refers to an orthogonal dimension of trait
affectivity reflecting the tendency to experience positive or rewarding emotional states and low reactivity
to negative stimuli (e.g., Berenbaum and Williams,
1995) and certain types of stressors (Clark and Watson, 1999). Affective disturbances consistent with this
pattern of traits are evident premorbidly among individuals who later develop schizophrenia (see Blanchard and Panzarella, 1998 for a review) and during
the early course of the disorder (Subotnik et al., 1999).
Additionally, traits that are conceptually and empirically linked to trait NA and trait PA such as neuroticism, introversion, and social anhedonia have been
shown to predict the later development of schizophrenia-related psychopathology (e.g., Angst and Clayton,
1986; Kwapil, 1998; Malmberg et al., 1998; Van Os
and Jones, 2001). Thus, the pattern of high trait NA
and low PA may be characteristic of many individuals
with schizophrenia throughout their lives rather than
solely reflecting the consequences of living with a
serious mental illness.
Schizophrenia is also associated with various manifestations of maladaptive coping style, including deficiencies in the use of active problem-focused coping
(van den Bosch et al., 1992), limited range and
flexibility of coping strategies, which are commonly
avoidant or passive (Dohrenwend et al., 1998; Jansen
et al., 1998), and ineffective interpersonal problemsolving strategies (e.g., submissiveness, lying, denial)
when confronted with negative emotions (Bellack et
al., 1992). While the pattern of high trait NA and
maladaptive coping style may serve to heighten sensitivity to stressors (e.g., Bolger, 1990; Bolger and
273
Zuckerman, 1995), low trait PA and low adaptive
coping style may reflect a lack of protective or
stress-buffering characteristics among individuals with
schizophrenia.
The current study examined the relationship
between affective traits and coping style and subjective emotional responses to stressful social interactions among individuals with schizophrenia. Selfreported negative and positive mood was examined
in schizophrenia outpatients and normal controls during a social role-play test (RPT), which was intended
to model a psychosocial stressor relevant to the daily
lives of individuals with schizophrenia. Participants
completed affective trait and coping style measures
and clinical symptom assessments. A brief neurocognitive test battery was also administered as neurocognitive deficits have previously been shown to
moderate vulnerability to stress in schizophrenia (Pallanti et al., 1997; Rosenfarb et al., 2000), and we
sought to evaluate the role of affective traits and
coping style above and beyond such deficits. It was
predicted that (1) the schizophrenia group would
demonstrate greater increases in negative mood and
decreases in positive mood than nonpsychiatric controls during the social RPT; (2) within the schizophrenia group, trait NA and maladaptive coping style
would be associated with elevations of negative mood
above and beyond clinical symptoms and neurocognitive functioning; (3) within the schizophrenia group,
higher levels of trait PA and adaptive coping style
would be associated with lower negative mood during
the RPT above and beyond clinical symptoms and
neurocognitive functioning.
2. Method
2.1. Participants
Participants included male schizophrenia outpatients (n = 36) recruited through a university-based
psychiatric hospital (n = 26) and a Veterans Administration Medical Center (n = 10), and nonpsychiatric
male controls (n = 15) recruited through newspaper
advertisements and flyers posted in the local community. DSM-IV (American Psychiatric Association,
1994) diagnoses of schizophrenia were based on the
Structured Clinical Interview for DSM-IV (SCID-I;
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W.P. Horan, J.J. Blanchard / Schizophrenia Research 60 (2003) 271–283
Table 1
Demographic characteristics for schizophrenia (n = 36) and control
(n = 15) groups
Age [M (SD)]
Education [M (SD)]
Ethnicity (%)
White
Black
Hispanic
Other
Marital status (%)
Married
Divorced
Separated
Never married
Schizophrenia
Controls
39.03 (12.24)
12.64 (2.00)
36.13 (7.90)
13.60 (2.26)
47.2
8.3
41.7
2.8
80.0
2.8
16.7
2.8
77.8
80.0
20.0
20.0
First et al., 1996). Patients with a history of tardive
dyskinesia (based on chart review) were excluded in
an effort to rule out organic factors, which may
contribute to cognitive or social dysfunctions that
are not necessarily attributable to schizophrenia per
se. Controls were screened for psychotic, mood, and
substance use disorders using the SCID and were
excluded for lifetime history of any psychotic or
mood disorder. Additional exclusion criteria for all
participants included (1) history of neurological disorder or head trauma with significant loss of consciousness, (2) mental retardation as indicated by
prorated IQ score from the two-subtest short form
of the WAIS-R, (3) current substance abuse or
dependence disorder, and (4) history of substance
dependence disorder within the past 4 years. All
participants provided informed consent to participate
in this project. Diagnostic interviews were videotaped and as previously described in a companion
study (Blanchard et al., 2001), adequate inter-rater
agreement was achieved with kappas ranging from
0.85 to 1.0.
Demographic information for patients and controls
is presented in Table 1. There were no differences
between groups on age, t(40.01) = 1.00, p > 0.05, or
education level, t(49) = 1.50, p>0.05. Chi-square analyses indicated that there were no group differences in
ethnicity v2(3,N = 51) = 5.07, p < 0.05. Consistent with
previous research, a smaller proportion of schizophrenia patients than controls had been married, v2(3,
N = 51) = 33.50, p < 0.001.
Clinical history information for patients is presented in Table 2. Patients were generally chronically
ill with a first psychiatric hospitalization occurring 10
to 20 years prior to participation in this project. All
patients were receiving antipsychotic medications that
were clinically determined. Antipsychotic medication
dosages were converted to chlorpromazine equivalents (Davis et al., 1983). A total of 13 patients were
taking traditional antipsychotics (chlorpromazine
equivalents, M = 570.28, SD = 477.49) and 15 were
taking atypical neuroleptics (e.g., risperidone, clozapine) for which there are no chlorpromazine unit
equivalents. Eight patients were involved in a double-blind neuroleptic trial (traditional versus novel
antipsychotic comparison) for which medication
assignment and dosage information is not available.
Symptomatology during the preceding week was
evaluated with an anchored version of the Brief
Psychiatric Rating Scale (BPRS; Overall and Gorham,
1962). Based on findings concerning the factor structure of the BPRS (Mueser et al., 1997), we utilized
four scales including Thought Disturbance, Anergia,
Affect, and Disorganization. Each subscale is based
on the sum of the items comprising the subscales. In a
companion project (Blanchard et al., 2001), adequate
inter-rater agreement was established between the
interviewers and a criterion rater (JJB) using 16
videotaped interviews (ICC = 0.78 for total 18-item
BPRS score). As may be seen in Table 2, the schizophrenia group demonstrated low to moderate levels
of symptomatology.
Table 2
Descriptive statistics for clinical history and symptoms in the
schizophrenia group (n = 36)
Measure
M (SD)
Age, first symptomsa
Age, first hospitalizationa
Years since first hospitalizationa
Brief Psychiatric Rating Scale
Anergia
Affect
Thought disturbance
Disorganization
Total score
21.33 (7.77)
21.34 (8.02)
17.5 (12.02)
5.89 (2.14)
11.36 (5.00)
6.94 (3.22)
4.33 (1.87)
30.75 (8.66)
a
Data missing for three participants due to inability to recall
information.
W.P. Horan, J.J. Blanchard / Schizophrenia Research 60 (2003) 271–283
2.2. Procedures and measures
Participation in this project involved two sessions
occurring on different days. During the first session,
participants were evaluated with the SCID to confirm
inclusion and exclusion criteria. The second session
was scheduled during the early afternoon and began
by obtaining a self-report measure of baseline mood.
Next, a member of the research team who did not
administer the diagnostic interview administered the
RPT. After each RPT scene, participants completed a
self-report mood questionnaire (total time to complete
the RPT was between 35 and 50 min). Participants
were then assessed with the BPRS (lasting approximately 25 min) and a brief cognitive test battery
(lasting approximately 60 min). Finally, participants
completed self-report trait and coping questionnaires.
This order of administration was selected to ensure
that a sufficient time interval existed between the
mood manipulation (RPT) and the completion of trait
and coping measures to prevent transient mood
changes from contaminating these self-report measures.
2.2.1. Role-play test
The role-play test (RPT) is a segment of the Social
Problem Solving Assessment Battery (Sayers et al.,
1995), a series of tasks specifically designed for use
with chronic psychiatric populations, which assess
participants’ ability to solve interpersonal problems
through conversation. This battery has high content
and social validity, good test – retest reliability across
different phases of illness, and has been shown to be
capable of identifying problem solving deficits among
individuals with schizophrenia (Bellack et al., 1994).
Our decision to utilize the role-play test as a
paradigm for examining emotional responses was
based on several considerations. First, role-play tests
have been used extensively in schizophrenia research
and provide a standardized method for examining
reactivity to putatively stressful interpersonal encounters. Second, schizophrenia patients frequently demonstrate severe social skill deficits on role-play tests
(Bellack et al., 1992), which might be expected to
elicit distress. Third, role-play tests share many characteristics with standardized psychosocial stress
induction procedures (e.g., public speaking tasks),
including a novel social context, unpredictability,
275
challenge, and changes in emotional valence (e.g.,
Bellack et al., 1992). Fourth, the validity of role-play
tests has been established in studies demonstrating
associations between RPT performance and community adjustment and functioning during interactions
with significant others (Bellack et al., 1990; Mueser
et al., 1990).
Participants were informed that the RPT procedure
would be videotaped using an unconcealed camera.
The procedure began by instructing participants to
read and then listen to an audiotaped description of
each role-play scene. Participants completed two 90-s
practice role-play scenes to ensure comprehension.
Each participant then completed four 3-min role-play
scenes. Two role-play scenes involved compromise
and negotiation (‘‘assertion’’ scenes) and required
participants to confront (a) a landlord about neglecting
to fix a leaky ceiling for several weeks and (b) a
supervisor about being dismissed from a job training
program. Two role-play scenes involved conversation
initiation and maintenance skills (‘‘affiliation’’ scenes)
and required participants to interact with (a) a new
neighbor in the process of moving into an apartment
and (b) a coworker at a new job. It was expected that
affiliation scenes would be experienced as both
unpleasant and aversive within the schizophrenia
group in light of the social anhedonia that is characteristic of schizophrenia (Blanchard et al., 1998, 2001),
the novel and evaluative context of the task, and the
skill deficits in initiating and sustaining conversations
that are often characteristic of schizophrenia. Assertion and affiliation RPT scenes were administered in a
fixed, alternating sequence, beginning with an assertion scene. Confederate responses were standardized
and primarily entailed open-ended or minimal
responses that required participants to control the flow
of conversation. Confederates were carefully trained
to use a consistent set of prompts and express a
neutral emotional tone.
2.2.2. Mood
A scale based upon the circumplex model of
emotion as explicated by Larson and Diener (1992)
was used to measure mood at baseline and following
each scene in the RPT. The scale is a 36-item selfreport questionnaire designed to provide a quick,
reliable, and valid measurement of pleasantness or
positive mood and unpleasantness or negative mood.
276
W.P. Horan, J.J. Blanchard / Schizophrenia Research 60 (2003) 271–283
The 18-item positive mood scale consists of items
tapping activated pleasant affect, pleasant affect, and
unactivated pleasant affect. The 18-item negative
mood scale consists of items reflecting activated
unpleasant affect, unpleasant affect, and unactivated
unpleasant affect. At baseline, participants rated the
extent to which they were ‘‘currently experiencing’’
each of the 36 mood adjectives on a 5-point scale
(very slightly or not at all, a little, moderately, quite a
bit, or extremely). Participants then completed the
scale after each of the four RPT scenes and were
instructed to rate the extent to which they experienced
each of the 36 mood adjectives ‘‘during the role-play
scene you just completed.’’ A full discussion of the
psychometric properties of the model upon which this
scale is based is presented in Larson and Diener
(1992). Internal consistency reliabilities (Chronbach’s
alpha) for the positive and negative mood scales were
very good in both the schizophrenia (median a = 0.95,
range = 0.93 – 0.97) and control (median a = 0.89,
range = 0.76– 0.98) groups.
2.2.3. Traits
Personality traits were measured with the 90-item
General Temperament Survey (GTS; Clark and Watson, 1990), which consists of three-factor analytically
derived scales that are answered in a true – false
format. Two scales were used in the current study:
Negative Temperament assesses trait NA and Positive
Temperament measures trait PA. The scales demonstrate good internal consistency reliabilities (alphas >0.85) and good convergent and discriminant
validity (Watson and Clark, 1992; Carver and White,
1994). Adequate psychometric properties have also
been demonstrated in schizophrenia populations
(Blanchard et al., 1998, 2001). Sample items from
the 28-item trait NA scale (possible range = 0 – 28)
include ‘‘I often find myself worrying about something’’ (keyed true), ‘‘I sometimes feel ‘just miserable’
for no good reason’’ (keyed true), ‘‘When I want to, I
can usually put fears and worries out of my mind’’
(keyed false). Sample items from the 27-item trait PA
scale (possible range 0 – 27) include ‘‘I am just naturally cheerful’’ (keyed true), ‘‘Most days I have
moments of real fun or joy’’ (keyed true), ‘‘I seldom
feel really happy’’ (keyed false). Internal consistency
reliabilities for the trait NA and trait PA scales were
very good in both the schizophrenia (a = 0.88 and 0.87,
respectively) and control (a = 0.92 and 0.88, respectively) groups.
2.2.4. Coping
Coping style was assessed with the 60-item dispositional version of the COPE (Carver et al., 1989).
The COPE assesses active and avoidant coping
efforts, as well as distinct aspects of active coping
and coping responses that might impede or interfere
with active coping that are not measured in other
instruments (e.g., denial, acceptance, behavioral disengagement). The COPE consists of statements
describing what people might do and feel when they
are under stress, which participants rate on a 4-point
likert scale, and yields 11 factors representing different types of coping strategies. The COPE scales
demonstrate adequate reliabilities and good convergent and discriminant validity (Carver et al., 1989,
1993).
To reduce the number of dependent variables, two
composite scales were selected on the basis of the
factor analytic and correlational work of Carver et al.
(1989) and previous research employing this instrument (Blanchard et al., 1999). An ‘‘adaptive coping’’
index was calculated by summing two scales utilized
in our earlier study that were highly correlated among
schizophrenia outpatients (r = 0.70; Blanchard et al.,
1999): 12 items from the ‘‘active coping’’ scale (based
on the following 4-item COPE subscales: active coping, planning, suppression of competing activities)
and 12 items from the ‘‘acceptance coping’’ scale
(based on the following 4-item COPE subscales:
restraint coping, positive reinterpretation and growth,
acceptance coping). Sample items from these subscales include, ‘‘I concentrate my efforts on doing
something about it’’ and ‘‘I try to see it in a different
light, to make it seem more positive’’. In the current
sample, the two previously developed active coping
and acceptance coping scales were highly intercorrelated (r = 0.74), as were the six COPE subscales
comprising the overall adaptive coping index (mean
r = 0.62, range = 0.52 – 0.79). The adaptive coping
scale (possible range: 24 – 96) demonstrated good
reliability in the schizophrenia (a = 0.91) and control
(a = 0.79) groups. As in our earlier study (Blanchard
et al., 1999), a ‘‘maladaptive coping’’ index was
calculated by summing the following 4-item COPE
subscales: denial, mental disengagement, and behav-
W.P. Horan, J.J. Blanchard / Schizophrenia Research 60 (2003) 271–283
ioral disengagement (possible range 12– 48). Sample
items from these scales include, ‘‘I turn to work or
other substitute activities to take my mind off of it’’
and ‘‘I pretend that it really has not happened’’. In the
current sample, the three COPE subscales comprising
the maladaptive coping index were moderately to
highly intercorrelated (mean r = 0.48, range = 0.32–
0.63). This scale demonstrated good internal consistency in the schizophrenia group (a = 0.81) but low
internal consistency in the control group (a = 0.40),
which may be associated with the relatively limited
range of scores on this scale among controls.
277
trait PA and high maladaptive coping and low adaptive coping in schizophrenia by examining group
differences on the trait and coping measures. Third,
correlational and regression analyses were conducted
within the schizophrenia group to examine associations between traits, coping, neurocognitive functioning and symptomatology, and changes in mood during
the RPT.
3. Results
3.1. Mood during the RPT
2.3. Cognitive functioning
2.3.1. General intellectual ability
General intellectual ability was assessed with an
abbreviated version of the Wechsler Adult Intelligence
Scale—Revised (WAIS-R, Wechsler, 1981). Vocabulary and Block Design were used as a two-subtest
short form of the WAIS-R. These subtests have high
reliabilities and have a higher correlation with the Full
Scale IQ scores than any other dyad (r = 0.90; Silverstein, 1982).
2.3.2. Memory
Selected subtests of the Wechsler Memory Scale—
Revised (WMS-R; Wechsler, 1987) were used to
assess verbal and visual memories. Immediate and
delayed (30 min) verbal memories were evaluated
with the Logical Memory I and II subtests, which
assess paragraph recall ability. Immediate and delayed
(30 min) visual memories were evaluated with the
Visual Reproduction I and II subtests, which assess
recall for basic geometric designs. All tests were
administered as described in the WMS-R Manual
(Wechsler, 1987).
Results for negative and positive mood during the
RPT are presented graphically in Fig. 1. For negative
mood, there was a significant main effect for condition, F(2,48) = 26.60, p < 0.001; however, the main
effect of group, F(1,49) = 3.82, and the group concondition interaction, F(2,48) = 0.13, were not significant ( p’s>0.05). Follow-up paired sample t-tests
across groups revealed higher negative mood during
assertion scenes than baseline, t(50) = 60.91,
p < 0.001, and higher negative mood during assertion
versus affiliation scenes, t(50) = 8.10, p < 0.001.
Negative mood during affiliation scenes did not differ
from baseline ( p>0.05).
For positive mood (see Fig. 2), there was a significant main effect for condition, F(2,48) = 33.74,
p < 0.001. The main effect of group, F(1,49) = 2.06,
and the group condition interaction, F(2,48) = 2.84,
were not significant ( p’s>0.05). Follow-up paired
samples t-tests across groups revealed that relative
2.4. Data analysis
Statistical analyses were conducted in three stages.
First, group differences in self-reported mood during
the RPT were examined to assess the validity of the
intended mood manipulation using 2 (group) 3
(baseline, assertion RPT scenes, affiliation RPT
scenes) repeated measures ANOVAs separately for
negative and positive mood. Second, we sought to
replicate previous findings of high trait NA and low
Fig. 1. Self-reported negative mood during the role-play test (Mood
Intensity scores for the RPT scenes are based on the averages of the
two assertion scenes and the two affiliation scenes).
278
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Table 3
Descriptive statistics for affective traits, coping style, and neurocognitive functioning in schizophrenia (n = 36) and control (n = 15)
groups
Scale
Fig. 2. Self-reported positive mood during the role-play test (Mood
Intensity scores for the RPT scenes are based on the averages of the
two assertion and the two affiliation scenes).
to baseline, participants reported lower positive mood
during the assertion scenes, t(50) = 7.78, p < 0.001,
and affiliation scenes, t(50) = 3.07, p < 0.01. Additionally, participants reported lower positive mood during
assertion scenes than during affiliation scenes,
t(50) = 7.40, p < 0.05.
Overall, assertion scenes elicited both increases in
negative mood and decreases in positive mood,
whereas affiliative scenes elicited decreases in positive mood but did not affect negative mood. The
schizophrenia and control groups did not differ in
their responses to the RPT scenes.
3.2. Affective traits, coping style, symptoms, and
neurocognitive functioning
Descriptive data for affective trait, coping style,
and neurocognitive measures in the schizophrenia and
control groups are presented in Table 3. Consistent
with previous research, the schizophrenia group demonstrated a pattern of high trait NA and low trait PA
and a coping style characterized by more common use
of maladaptive coping strategies. Although the group
means differed in the predicted direction for adaptive
coping (schizophrenia lower than controls), this difference was not statistically significant. Neurocognitive
test results indicated that the schizophrenia group
performed worse than controls across the measures
of general intellectual and memory functioning
included in this study ( p’s < 0.05) with the exception
of WMS-R Visual Reproduction I ( p = 0.10).
Correlational analyses within the schizophrenia
group involving self-reported mood during the RPT,
traits, coping, neurocognitive tests, and symptom
General Temperament
Survey
Trait NA
Trait PA
COPE
Maladaptive coping
Adaptive coping
Estimated Full Scale
IQ score
Wechsler Memory
Scale—Revised
Logical Memory I
Logical Memory II
Visual
Reproduction I
Visual
Reproduction II
Schizophrenia Controls
[M (SD)]
[M (SD)]
t
12.25 (6.59)
16.31 (6.27)
7.07 (6.39)
20.47 (5.46)
2.58**
2.24*
25.58 (6.97)
66.39 (13.94)
93.25 (11.19)
17.87 (2.90)
70.27 (7.02)
106.73 (12.06)
5.59**
1.32
3.84**
20.28 (8.35)
16.67 (8.30)
33.03 (5.30)
31.20 (8.01)
27.27 (8.80)
35.67 (4.45)
4.31**
4.08**
1.69
28.36 (8.53)
33.73 (7.17)
2.14*
NA = negative affectivity, PA = positive affectivity.
* p < 0.05.
** p < 0.01.
measures focused on assertion RPT scenes, as affiliation scenes did not result in significant increases in
negative mood. As shown in Table 4, negative mood
during assertion RPT scenes correlated positively with
baseline negative mood, trait NA, maladaptive coping, BPRS total scores, and WMS-R Visual Reproduction II scores. Contrary to expectations, negative
mood also positively correlated with adaptive coping.
Positive mood during assertion RPT scenes correlated
positively with baseline positive mood and negatively
with WMS-R Visual Reproduction I scores, but was
not significantly correlated with trait, coping, or
symptom measures.2
To determine whether trait NA and maladaptive
coping demonstrate an association with negative
mood during the RPT above and beyond baseline
2
A parallel set of correlational analyses was conducted among
the normal controls. Results indicated that maladaptive coping style
positively correlated with baseline negative mood (r = 0.78,
p < 0.001). However, all other relationships among traits and coping
and negative mood during the RPT and neurocognitive test scores
were nonsignificant. These null findings should be interpreted
cautiously due to the small sample size in this group.
W.P. Horan, J.J. Blanchard / Schizophrenia Research 60 (2003) 271–283
279
Table 4
Correlations between self-reported mood during assertion role-play tests and other variables among schizophrenia patients (n = 36)
1
(1) Assertion NM
(2) Assertion PM
(3) Baseline NM
(4) Baseline PM
(5) Trait NA
(6) Trait PA
(7) Maladaptive coping
(8) Adaptive coping
(9) BPRS total
(10) Estimated IQ
(11) WMS-R Verbal I
(12) WMS-R Verbal II
(13) WMS-R Visual I
(14) WMS-R Visual II
2
–
0.16
0.52**
0.16
0.57**
0.05
0.56**
0.38*
0.40*
0.21
0.17
0.22
0.18
0.39*
3
–
0.09
0.63**
0.00
0.05
0.28
0.07
0.10
0.29
0.17
0.13
0.42*
0.18
4
–
0.10
0.36*
0.01
0.35*
0.16
0.17
0.14
0.30
0.36*
0.38*
0.37*
5
–
0.03
0.29
0.26
0.38*
0.08
0.18
0.09
0.05
0.20
0.20
6
–
0.16
0.40*
0.16
0.57**
0.01
0.16
0.17
0.24
0.27
7
–
0.05
0.16
0.04
0.29
0.09
0.04
0.04
0.13
8
–
0.11
0.11
0.24
0.09
0.03
0.32
0.26
9
–
0.32
0.07
0.22
0.21
0.21
0.32
–
0.03
0.40*
0.39*
0.19
0.20
10
11
12
13
–
0.41*
0.40*
0.31
0.50**
–
0.95** –
0.19
0.32
–
0.40* 0.47** 0.74**
NM = negative mood, PM = positive mood, NA = negative affect, PA = positive affect, BPRS = Brief Psychiatric Rating Scale, and WMSR = Wechsler Memory Scale—Revised.
* p < 0.05, two-tailed.
** p < 0.01, two-tailed.
negative mood in the schizophrenia group, variables
were entered into a hierarchical multiple regression
equation in the following order: (1) baseline negative
mood, (2) trait NA, and (3) maladaptive coping. Our
decision to enter trait NA prior to maladaptive coping
was motivated by theoretical and empirical considerations regarding the proposal that personality traits
may influence stress reactivity through their affects on
differential choice or effectiveness of coping strategies
(Bolger and Zuckerman, 1995). As can be seen in
Table 5, baseline mood accounted for 27% of the
variance in assertion negative mood, which was
statistically significant. Trait NA and maladaptive
coping accounted for 17% and 8% of the variance
Table 5
Hierarchical linear multiple regression analysis for negative mood
during assertion role-play test scenes in the schizophrenia group
(n = 36)
Variables by block
R2
DR2
DF
(1) Baseline negative mood
(2) Trait NA
(3) Maladaptive coping
0.27
0.44
0.52
0.27
0.17
0.08
12.69***
9.83**
5.55*
NA = negative affectivity.
* p < 0.05.
** p < 0.005.
*** p < 0.001.
in negative mood, respectively, which were both
statistically significant.3 Thus, trait NA and maladaptive coping accounted for a significant portion of
variance in subjectively experienced social stress
during the RPT above and beyond that accounted
for by baseline mood.
Additional analyses were conducted within the
schizophrenia group to determine whether trait NA
and maladaptive coping account for variance in negative mood during the RPT above and beyond symptoms and cognitive factors found to be correlated with
negative mood. Variables were entered into a regression equation in the following order: (1) baseline
negative mood, (2) BPRS total score, (3) WMS-R
Visual Reproduction II score, (4) trait NA, and (5)
maladaptive coping. Again, baseline mood accounted
for a significant amount of variance in assertion
negative mood (DR2 = 0.27, DF = 12.69, p < 0.001).
3
An additional regression analysis was conducted entering
adaptive coping into the regression equation after baseline mood
and prior to trait NA and maladaptive coping. Results were
essentially unchanged. Adaptive coping accounted for a significant
proportion of variance (DR2 = 0.09, DF = 4.76, p < 0.05), and trait
NA accounted for slightly less variance (14%) while maladaptive
coping accounted for the same proportion of variance (8%), which
were both statistically significant.
280
W.P. Horan, J.J. Blanchard / Schizophrenia Research 60 (2003) 271–283
The addition of total BPRS scores accounted for a
significant increment of variance in the equation
(DR2 = 0.17, DF = 5.37, p < 0.05) but Visual Reproduction II did not ( p>0.05). Subsequently, trait NA
(DR2 = 0.07, DF = 4.11, p = 0.05) and maladaptive
coping (DR 2 = 0.09, DF = 5.83, p < 0.05) each
accounted for significant increments of variance in
self-reported negative mood.
4. Discussion
This study examined subjective emotional responses to putatively stressful social interactions among
individuals with schizophrenia and their relationship to
individual differences in affective traits and coping.
During the RPT, assertion scenes elicited increased
negative mood and decreased positive mood that was
similar in magnitude across patients and controls,
whereas affiliation scenes led to similar decreases in
positive mood across groups but did not significantly
affect negative mood. These patterns indicate that
assertion scenes elicited greater subjectively experienced stress during the RPT than the affiliation scenes.
The similar mood changes across groups are consistent
with studies demonstrating that individuals with schizophrenia report emotional changes similar to nonpsychiatric controls when confronted with nonsocial,
emotionally valenced stimuli (see Kring, 1999),
although there was no evidence for the prediction that
the schizophrenia group would report higher levels of
negative mood than controls during the RPT. Overall,
results support the notion that individuals with schizophrenia are sensitive and responsive to emotionally
evocative stimuli and extend this line of research to the
domain of social interactions.
The current findings provide preliminary support
for the utility of the social RPT as a laboratory paradigm to examine psychosocial stress reactivity in
schizophrenia. An appealing feature of the RPT is its
apparently greater ecological validity for examining
psychosocial stress among individuals with schizophrenia than other commonly used procedures (e.g.,
public speaking tasks), as stressors that occur within
the context of interpersonal interactions appear particularly important in schizophrenia (e.g., Butzlaff and
Hooley, 1998). However, the lack of group differences
in self-reported mood suggests the procedure may not
have been sufficiently challenging or distressing to
detect heightened emotional responses in the schizophrenia group and could benefit from methodological
refinement. For example, the lack of negative mood
evoked by the affiliation scenes suggests that such
role plays may not be ideal for examining stress reactivity. Furthermore, while the decreases in positive
mood during the affiliation scenes could potentially be
interpreted as consistent with social anhedonia within
the schizophrenia group (Blanchard et al., 2001), the
controls apparently experienced these scenes as equally unrewarding. Thus, refinements aimed at increasing
the duration and intensity of negative mood elicited
by the RPT (e.g., replace affiliation scenes with other
types of negative mood-inducing scenes) could render
the task more well suited to examine emotional responses to stress as well as associated hormonal (e.g.,
HPA axis activation) and autonomic nervous system
responses.
The most significant findings from this study
concern the relationships between affective traits,
coping style, and mood changes during confrontational social interactions in schizophrenia. Whereas
studies of demographic and clinical characteristics
have yielded little in accounting for differences in
responses to stressors, our results suggest that enduring psychological characteristics play a meaningful
role in understanding differences in subjectively
experienced stress among individuals with schizophrenia. Trait NA and maladaptive coping uniquely
accounted for approximately one quarter of the variance in negative mood during assertion RPT scenes
above and beyond baseline mood and continued to
significantly account for variance in negative mood
after controlling for clinical symptomatology and
neurocognitive functioning. These results extend the
stress-modulating effects of trait NA and maladaptive
coping found in a variety of clinical and nonclinical
populations (e.g., Bolger and Zuckerman, 1995;
Clark et al., 1994; Skodol, 1998; Taylor and Aspinwall, 1996) to schizophrenia. These results are the
first to demonstrate an association between repeated
observations of elevated trait NA in schizophrenia
(Berenbaum and Fujita, 1994; Blanchard et al., 1998,
2001) and emotional responses during social interactions and encourage further research into the role of
this affective trait in the stress exposure – relapse
process.
W.P. Horan, J.J. Blanchard / Schizophrenia Research 60 (2003) 271–283
It is important to note several limitations of the
current study. Findings regarding the role of trait NA
and maladaptive coping are based on self-report and
may partly reflect method variance. We were, however,
able to demonstrate that these variables accounted for
variance in negative mood during the RPT above and
beyond baseline mood, clinical ratings of symptomatology, and performance on neurocognitive tasks. This
issue can be more directly addressed by incorporating
measures of additional components of the stress process, such as hormonal or autonomic reactivity (e.g.,
Jansen et al., 1998, 2000). The cross-sectional design
of this study did not allow us to examine the stability of
the affective traits and coping styles examined or
determine whether these traits reflect premorbid personality characteristics in the current sample. It is
unclear to what extent the various medications taken
in the schizophrenia group may have affected emotional responding (Blanchard and Neale, 1992),
although similar patterns of self-reported mood have
been found in unmedicated patients exposed to nonsocial emotionally evocative stimuli (e.g., Kring and
Neale, 1996). Finally, it is unclear whether the current
findings are generalizable to the emotional responses of
women diagnosed with schizophrenia (Salem and
Kring, 1998).
In this study, it was demonstrated on a preliminary
basis that trait NA and maladaptive coping style are
meaningfully associated with variability in emotional
responding to psychosocial stress among individuals
with schizophrenia. It will be important to determine
whether trait NA and/or maladaptive coping are
specific vulnerability factors that amplify stress reactivity in schizophrenia or simply reflective of more
general tendencies toward distress (Cohen and Wills,
1985). The relationship between traits and coping in
the stress process in schizophrenia also requires
clarification. Evaluation of more specific facets of
affective traits and coping style (e.g., cognitive
appraisals) may facilitate identification of individuals
at elevated risk for stress-induced relapse as well as
stress-buffering factors, as trait PA and adaptive
coping style may lack the sensitivity necessary to
detect personal protective factors in schizophrenia.
Continued investigation of trait NA and maladaptive
coping style holds promise for identifying physiological factors that may contribute to abnormal stress
reactivity in schizophrenia (e.g., Depue, 1996) and
281
tailoring psychosocial interventions (e.g., affect regulation or coping skill interventions) to individual
patient characteristics.
Acknowledgements
Portions of this research were presented at the 2000
Annual Meeting of the Society for Research in
Psychopathology, Boulder, CO. This research was
supported by Grant MH-51240 from the National
Institute of Mental Health.
The authors thank Seth Brown and Andrea Sherwood for their assistance in data collection.
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