Differential effects of coping in mental disorders: A prospective study in psychiatric outpatients

Originallypublished inVolume 52,Number 2, 1996,pages 125–135.

Differential Effects of Coping in Mental Disorders:A Prospective Study in Psychiatric Outpatients

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Margarete Vollrath

University of Zurich

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Randolf Alnæs and Svenn Torgersen

University of Oslo

The present follow-up study investigated the differential effects of dispo-sitional coping styles on change in nine clinical syndromes of the Axis Ispectrum of the DSM-Ill-R. Subjects were 155 psychiatric outpatients whowere examined 6 and 7 years after their enrollment in the study. Copingaccounted for up to 9% of the variance of symptom change over 1 year.As hypothesized, the effects of different coping styles varied considerablyacross the clinical syndromes. Active goal-oriented coping improved symp-toms of the anxiety and the dependency spectrum; seeking social supporthad beneficial effects on symptoms of the depressive spectrum. The effectsof the coping styles distraction, use of alcohol and other drugs, and focus-ing on and venting of emotions were detrimental, but again in a specificway. The results suggest that the differentiation of outcome criteria forcoping is important. © 2003 Wiley Periodicals, Inc. J Clin Psychol 59:1077–1088, 2003.

According to Lazarus’ theory of stress and coping (Lazarus & Folkman, 1984), the out-come of stressful events depends largely on our coping efforts. However, coping is notrestricted to the successful mastery of stressful encounters, but, rather, encompasses allbehaviors and thoughts aimed at the management of the actual situation (problem-focused coping) and the concomitant emotional reactions (emotion-focused coping). A

This study was supported by grants from the Norwegian Research Council for Science and the Humanities andby legacies administered by the University of Oslo, the Lier Hospital Foundation, the Anders Jahres Founda-tion, and the Solveig and Johan P. Sommers Legacy. The authors wish to thank Karola Vollrath for polishingthe English.Correspondence should be addressed to Margarete Vollrath, Ph.D., Department of Social Psychology, Univer-sity of Zurich, Rämistr. 66, 8001 Zurich-Switzerland.

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 59(10), 1077–1088 (2003) © 2003 Wiley Periodicals, Inc.

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.10200

third category, avoidance coping, is partly considered to belong to the latter spectrum(Aldwin & Revenson, 1987; Lazarus & Folkman, 1984), partly as an entirely differentcategory (Amirkhan, 1990; Endler & Parker, 1990).

One of the main foci in research on coping has been the identification of strategieswith a beneficial impact on adjustment to stress. Countless cross-sectional and fewerprospective studies have been conducted with this aim. Among the many different copingstrategies that were examined, three kinds of strategies have emerged as being significantfor mental health, namely, problem-focused coping, seeking social support, and avoid-ance coping.

Problem-focused coping appears to have a beneficial potential because, according toseveral studies, it shows a negative relation to concurrent symptoms of mental disorders(Billings, Cronkite, & Moos, 1983; Bruder-Mattson & Hovanitz, 1990; Kleinke, 1988;Olah, Törestad, & Magnusson, 1989; Vitaliano et al., 1987; Vitaliano et al., 1990; Vitaliano,Russo, Carr, Maiuro, & Becker, 1985). The evidence is not unambiguous, however, becausea number of other studies failed to find a relation (Blankstein, Flett, & Watson, 1992;Chan, 1992; Coyne, Aldwin, & Lazarus, 1981; Hovanitz, 1986; Parker & Brown, 1982).Crucial for determining the effectiveness of coping, however, are the results of prospec-tive studies. Again, the evidence is ambiguous. When prior symptoms were controlled,problem-focused coping predicted decrease or stability of global psychological and depres-sive symptoms, which points to true beneficial effects (Aldwin & Revenson, 1987; Felton& Revenson, 1984; Holahan & Moos, 1990; Swindle, Cronkite, & Moos, 1989). How-ever, the opposite also was found. Problem-focused coping actually predicted an increaseof anxiety or feelings of threat among students in an examination phase, for instance(Bolger, 1990; Carver & Scheier, 1994). The disparity among results might be explainedby differences among the outcome measures.

The relation of seeking social support with symptoms of mental disorders is contra-dictory. Cross-sectionally, anxiety disorders or symptoms of anxiety were found to beassociated with increased seeking of social support (Borden, Clum, Broyles, & Watkins,1988; Vitaliano et al., 1985; Vollrath & Angst, 1993). This may be explained with the helpof a mobilization hypothesis. Depression, on the other hand, was found to be associatedboth with increased (Coyne et al., 1981) and decreased seeking of support (Kleinke,1991; Parker & Brown, 1982). In another study, decreased seeking of social supportwas related to both anxiety and depression (Vollrath, Alnæs, & Torgersen, 1994b). Find-ings from longitudinal studies do not seem more conclusive. Aldwin and Revenson (1987)found that support mobilization increased psychological symptoms 1 year later, and Carverand Scheier (1994) reported that seeking for support increased feelings of threat amongstudents during an examination phase. Another prospective study reported that seekingsocial support decreased depressive symptoms in pain patients (Kleinke, 1992). Again, itmay be possible that seeking social support yields different effects depending on themental disorder under investigation.

Among the emotion-focused strategies, avoidance coping was found to be relatedmost consistently to different symptoms of mental disorders. Cross-sectionally, this hasbeen shown for patients with psychiatric problems (Billings et al., 1983; Billings &Moos, 1984; Borden et al., 1988; Kleinke, 1988; Parker & Brown, 1982; Vitaliano et al.,1990; Vitaliano et al., 1985; Vollrath, Alnæs, & Torgersen, 1994a; Vollrath et al., 1994b),as well as for patients with physical health problems (Kleinke, 1988, 1992). Avoidancecoping is a heterogeneous class of coping that comprises cognitive strategies, suchas day-dreaming and wishful thinking (Coyne et al., 1981), distractive behaviors, such aswatching TV or sleeping, and strategies that remind of psychiatric symptoms, such astaking medication (Parker & Brown, 1982), taking alcohol or drugs (Carver, Scheier, &

1078 Journal of Clinical Psychology, October 2003

Weintraub, 1989; Miller, Surtees, Kreitman, Ingham, & Sashidharan, 1985), or blamingoneself (Aldwin & Revenson, 1987). Prospectively, negative effects of avoidance ondifferent criteria for mental health have been demonstrated (Aldwin & Revenson, 1987;Carver & Scheier, 1994; Felton & Revenson, 1984; Hoffart & Martinsen, 1993; Kleinke,1992; Miller et al., 1985). Therefore, avoidance coping is considered to be maladaptiveand a risk factor for psychological adjustment by many authors (Carver et al., 1989;Felton & Revenson, 1984; Holahan & Moos, 1987; Miller et al., 1985; Vitaliano, Russo,Young, Teri, & Maiuro, 1991). However, given the stability of symptoms over time(Kessler, 1983), the amount of variance explained by avoidance coping tends to besmall, and there is an increasing number of studies that failed to find effects when priorsymptoms of mental disorders were controlled (Carver et al., 1993; Holahan & Moos,1987; Lackner et al., 1993; Smith, Patterson, & Grant, 1990; Swindle et al., 1989;Vitaliano et al., 1991).

Taken together, it does not seem to be evident which coping strategies should beconsidered as helpful and which as maladaptive for mental health. One important step inthe direction of achieving more clarity would be a better differentiation among outcomeindicators. Most studies considered only one (e.g., a general symptom scale) or twooutcomes measures. However, coping strategies that work for anxiety disorders, for instance,need not necessarily be optimal for depressive disorders, as indicated also by studies ondifferent mental disorders (Borden et al., 1988; Kashani & Orvaschel, 1988; Vitalianoet al., 1985; Vollrath et al., 1994b). Furthermore, the effects of coping may be sampledependent, and findings obtained in the general population may not apply to more severelydisordered psychiatric patients.

Furthermore, we argue that for the prediction of mental health, stable rather thanvariable aspects of coping should be examined. When specific stressful events are beinganalyzed, it is certainly useful to assess coping in a context-specific way, as claimed byseveral authors (Carver et al., 1993; Carver et al., 1989; Folkman & Lazarus, 1985;Lazarus, 1983; Lazarus & Folkman, 1984). However, context-specific coping is influ-enced more strongly by situational variation and chance and can best be conceived as apredictor of short-term fluctuations of adaptation. If coping is to predict long-term out-come of mental health, then coping dispositions should be studied that act as predictors ofcoping behaviors across situations and over time. This argument is supported by evi-dence for the stability of coping over time, particularly with respect to emotion-focusedcoping and to avoidance strategies (Billingsley, Waehler, & Hardin, 1993; Carver &Scheier, 1994; Filipp, Klauer, Freudenberg, & Ferring, 1990; Folkman, Lazarus, Gruen,& DeLongis, 1986; Swindle et al., 1989). Furthermore, the associations of emotion-focused coping and avoidance with enduring personality traits, such as extraversion,neuroticism, or optimism (Aspinwall & Taylor, 1992; Bolger, 1990; Carver et al., 1989;Holahan & Moos, 1987; McCrae & Costa, 1986; Parkes, 1986; Scheier, Weintraub, &Carver, 1986; Smith, Pope, Rhodewalt, & Poulton, 1989; Terry, 1991; Vollrath, Ban-holzer, Caviezel, Fischli, & Jungo, 1994; Vollrath, Torgersen, & Alnæs, 1995) may serveas further indicators.

With regard to psychiatric disorders, adequate coping skills are of great importancebecause the disorder itself constitutes a vulnerability factor in the stress process. Yet, toour knowledge, only a few studies have investigated whether the psychiatric patients’coping styles could predict their future symptomatology. Hoffart and Martinsen (1993)found no effect of coping on depressive disorder. However, high levels of seeking socialsupport and low levels of avoidance predicted decreased fear of fear among agoraphobicpatients. In the study by Veiel, Kühne, Brill, and Ihle (1992), seeking social supportpredicted recovery among depressed inpatients without a partner. Swindle et al. (1989)

Effects of Coping in Mental Disorders 1079

reported that coping predicted the course of unipolar depression when concurrent copingwas considered. However, no effects were found for antecedent coping.

In the present study, the effectiveness of coping for change of different DSM-III-R(American Psychiatric Association, 1987) Axis I syndromes was studied in a sample ofpsychiatric outpatients. The following questions were addressed: Can dispositional cop-ing styles predict the course of psychiatric symptomatology? Are different Axis I syn-dromes predicted by the same or by different coping strategies? Which coping strategiespredict decrease of symptoms, and which predict increase?

Method

Subjects

The present study investigated a sample of psychiatric outpatients 6 and 7 years aftertheir first admission. The initial sample of 298 patients was drawn in 1984–1985 from theoutpatient section of the Department of Psychiatry, University of Oslo, which serves acatchment area of 70,000 inhabitants. Patients were referred by a general practitioner orthe local health center. Inclusion in the study was limited to those who had an Axis I orAxis II disorder according to the Diagnostic and Statistical Manual for Mental Disor-ders, Third Edition (DSM-III; American Psychiatric Association, 1980). Patients withacute psychosis, acute crisis, substance abuse, organic mental disorder, or social prob-lems were excluded. The 298 patients were interviewed personally by a psychiatrist (R.A.)(Alnæs & Torgersen, 1988a, 1988b). In addition, a questionnaire for the assessment ofpsychiatric symptoms was filled in by 272 of these patients.

Procedure

After 6 years (1991), 284 of the patients could be reinterviewed, and 239 of them filled inthe questionnaire on psychiatric symptoms and a coping styles inventory. One year later(1992), 7 years after the initial interview, the psychiatric symptoms questionnaire wasmailed to the patients, and 165 valid questionnaires were returned. Among the respond-ers, 10 had not filled in questionnaires in 1991. This left a sample of 155 persons for theprospective analysis.1

Measures

The psychiatric symptom questionnaire was the Millon Clinical Multiaxial Inventory(MCMI-II; Millon, 1987)2, a diagnostic self-report instrument for psychiatric patientsthat is consonant with the DSM-III-R (American Psychiatric Association, 1987) diagnos-tic system and labels. It measures the more acute clinical syndromes of Axis I as well aspersonality characteristics (disorders) of Axis II. The scales anxiety, somatoform, bipolar/manic, dysthymia, alcohol dependence, and drug dependence assess moderately “neu-rotic” forms of psychopathology; the scales thought disorder, major depression, anddelusional disorder show parallel features of a more psychotic nature (Millon, 1987). The

1The 155 responders were compared to the remainder of the sample with respect to the scores they had obtainedin the psychiatric symptoms questionnaire at enrollment in the study. No significant differences were found forany of the clinical symptom scales.2 At enrollment in the study the MCMI (Millon, 1983) was used.


scales are not conceived as discrete diagnoses, but as elements of a profile of clinicalfeatures.

Coping strategies were assessed with the COPE, a 60-item self-report inventory thatmeasures 15 dispositional coping strategies (styles) used across stress situations. Eachitem is a statement worded in the first person that indicates the use of a particular copingresponse and is rated on a 4-point scale, which ranges from “I usually don’t do this at all”to “I usually do this a lot.” Five scales assess problem-focused coping, 5 assess emotion-focused coping, and 5 measure potentially dysfunctional coping styles. The discriminantvalidity of the coping styles with regard to a wide range of personality traits has beendemonstrated (Carver et al., 1989).

To reduce the number of coping styles for the present study, we followed an approachby Carver and Scheier (1994) and collapsed several intercorrelated scales. The scalesactive coping, planning and suppression of competing activities were combined into activegoal-oriented coping. The scales seeking of social support for instrumental reasons andseeking social support for emotional reasons were combined into seeking social support.The latter scale comprises both problem-focused and emotion-focused aspects of coping.All scales showed acceptable internal consistencies that ranged between � � .60 and � �.96 with the exception of the scale distraction (original label: mental disengagement)(Cronbach’s � � .50).

Results

Because the strongest predictor of future mental health is current mental health (Kessler,1983), prior symptoms had to be controlled to determine whether coping explains anyadditional variance. In a first step, this was carried out by means of partial correlations,with previous symptoms partialled out for every scale.3 Table 1 shows the partial corre-lations between antecedent coping and residualized subsequent MCMI-II symptom scales.The coping scales of active, goal-oriented coping, distraction, focusing on and venting ofemotions, and use of alcohol/medication or drugs were related significantly to sub-sequent symptoms after controlling for prior symptoms. In the next step, hierarchicalmultiple regression analyses were used to determine which patterns of coping strategieswere the best predictors of every MCMI-II symptom scale and what amount of variancethey explained. A first series of hierarchical multiple regression analyses showed that ageand sex did not contribute significantly to the variance of symptom change. Thus, thesevariables were dropped for the definite analyses. Table 2 presents the nine definite regres-sion analyses. The MCMI-II symptom scales in 1992 were the dependents, and the cor-responding symptom scale in 1991 (Time 1) was entered as the first predictor (Menard,1991). In the following, coping styles were entered stepwise as long as they produced asignificant increment to the total regression equation.

As expected, previous symptoms were by far the strongest predictors of subsequentsymptoms, with betas that ranged between .64 and .76 before coping was entered into theequations. Table 2 (bottom) lists the increments of explained variance (R2 ) produced bythe coping styles. Coping accounted for 4% to 9% of the variation for seven of the nineMCMI-II symptom scales. This amounts to up to 16% of the unexplained variance ofsymptoms in 1992. The only clinical syndromes that were not predicted by coping werethe bipolar/manic syndrome and delusional disorder. In both cases, the stability of thedisorder was very high.

3 Separate analyses were conducted for age and sex. Neither age nor sex predicted subsequent symptoms afterprior symptoms were controlled. Therefore, these two variables were excluded from further analyses.


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The strategies of active, goal-oriented coping, seeking social support, distraction,focusing on and venting of emotions, and use of alcohol and drugs were the most importantpredictors of symptom change. Active, goal-oriented coping and seeking social supportwere predictors of decreased scores on the symptom scales, while the other three copingstrategies predicted an increase of the scores.

The effect of different coping styles varied among the scales. The strategy of ac-tive, goal-oriented coping predicted a decrease of symptoms for anxiety disorder,somatoform disorder, alcohol dependence, and thought disorder, but it had no effect fordysthymia and major depression. Seeking of social support predicted a decrease of symp-toms exclusively for dysthymia and major depression. Distraction predicted increasedscores on the scales of dysthymia, major depression, and delusional disorder. Focusingon and venting of emotions was the best prospective predictor of symptoms andpredicted increased scores on six of nine symptom scales. Use of alcohol or drugsenhanced symptoms of thought disorder and delusional disorder, but not of alcoholdependence or drug dependence.

Discussion

The present study shows that dispositional coping is a moderate, but significant, prospec-tive predictor of symptom change among psychiatric outpatients. Active, goal-orientedcoping and seeking emotional and instrumental support emerged as potential resources inthe stress process, while the strategies of distraction; focusing on and venting of emo-tions; and use of alcohol or drugs operated as risk factors for mental disorders. Thesefindings must be considered in light of the almost trait-like stability of symptoms ofmental disorders (Kessler, 1983), a fact that severely limits the predictive power of anyadditional variable. This is probably the reason why several recent longitudinal studiesdid not yield any effects of antecedent coping on mental disorder when prior symptomswere controlled (Carver et al., 1993; Holahan & Moos, 1987; Lackner et al., 1993; Smithet al., 1990; Swindle et al., 1989; Vitaliano et al., 1991).

Our results demonstrate that coping has a differential impact on various clinicalsyndromes. Not only the amount of variance of symptoms at follow-up accounted for bycoping varied considerably, but also the patterns of coping strategies being predictive forthe different disorders.

In our study, active coping was beneficial for anxiety disorder, somatoform disorder,and thought disorder, but not for affective disorders. This is not in line with the onlycomparable study on psychiatric outpatients, in which problem-focused coping influ-enced neither depression nor anxiety (Hoffart & Martinsen, 1993). In contrast, seekingsocial support only showed positive effects on depressive symptomatology. This is in linewith a study on depressed inpatients, in which support seeking predicted recovery if thepatients had no partner (Veiel et al., 1992), but at odds with the findings of Hoffart andMartinsen (1993), in which support seeking did not improve depression, but anxiety.

Distraction proved to be maladaptive with respect to dysthymia and to the moresevere disorders of major depression and delusional disorder, thus suggesting that it maybe a facet of unreality-feeling. Distraction is similar to avoidance coping, which hasshown maladaptive effects on global symptoms or negative mood in several studies (Ald-win & Revenson, 1987; Aspinwall & Taylor, 1992; Felton & Revenson, 1984; Kleinke,1992; Miller et al., 1985). Other evidence suggests that avoidance is also maladaptive foranxiety (Bolger, 1990; Carver & Scheier, 1994; Hoffart & Martinsen, 1993).

However, a comparison of our findings with other studies is difficult because thereare so few prospective studies that examine more than one syndrome scale or psychiatric


diagnosis. Furthermore, the studies reviewed for the present article have employed verydiverse coping scales (and none of them the COPE), which renders a comparison evenmore speculative.

Two further coping strategies that rarely have received attention to date were iden-tified as important negative predictors of mental health. Focusing on and venting ofemotions clearly emerged as a harmful coping style for mental health. In a previous study,venting emotions proved to be cross-sectionally related to most of the clinical syndromesof the MCMI-II (Vollrath et al., 1994b). A similar strategy, emotional discharge, wasshown to be related to depression (Billings et al., 1983; Billings & Moos, 1984; Folkman& Lazarus, 1988; Swindle et al., 1989). Presumably, the negative effects of focusing onand venting of emotions are mediated by their effects on the social network. The expres-sion of negative feelings often elicits negative responses among social partners and putsstrain on a relationship or may even lead to its break-up, which, in turn, may be the reasonfor less available social support (Dunkel-Schetter & Bennett, 1990).

The coping style of using alcohol, tablets, or drugs was a further predictor of deteri-oration of mental health. Because this strategy potentially is confounded with the symp-toms of substance abuse or dependence, a relation with alcohol dependence was expected.Instead, a prospective relation with the scales of thought disorder and delusional disorderwas found. Thus, similarly to distraction, the consumption of alcohol or other psycho-active substances to help dealing with stress may foster detachment from reality.

Several methodological considerations have to be mentioned with regard to the presentstudy. Firstly, the causal direction between coping and symptoms cannot be establishedfirmly by our design. It cannot be excluded that coping is the result, rather than the causeof mental disorders. Some evidence suggests that maladapative strategies, such as avoid-ance, are state-dependent and subside when symptoms remit (Billings & Moos, 1985;Parker & Brown, 1982; Veiel et al., 1992) and that there are interactions between symp-toms and choice of coping strategy (Aspinwall & Taylor, 1992; Filipp et al., 1990). Theissue of reverse causation can only be addressed in studies with repeated assessments ofboth symptoms and coping. However, coping was not assessed twice in our study.

Furthermore, as mentioned before, there is a certain overlap of content betweensymptoms of mental disorders and coping strategies. For instance, avoidance and with-drawal tendencies overlap with some of the criteria for anxiety disorders, especiallyphobias. Consumption of psychoactive substances to regulate mental states is a featurein dependency and abuse. Venting of emotions is a feature of manic disorder. A solu-tion to this problem is not readily available because stripping coping inventories of allpotentially confounding items also would strip them of some of their most importantcontent.

In spite of these limitations, the results of the present study support the notion thatcoping does predict the course of mental disorders. To that end, dispositional copingstyles can be more powerful predictors than coping with a single situation. This notion issupported by interventions in which coping skills are taught with very good results. Intwo recently published articles, it was demonstrated that among cancer patients, the train-ing of coping skills not only helped improving mental health, but even influenced sur-vival rates (Fawzy et al., 1990; Fawzy et al., 1993).

Most importantly, for the understanding of the effectiveness of coping, a differenti-ation of outcome criteria of mental health is necessary. Well-being cannot be equatedsimply with the absence of symptoms on a single scale. It also is important to conductstudies that address the effects of coping on mental disorders as assessed by standardizedinterviews. Finally, the role of self-focused attention and emotional discharge for mentalhealth certainly deserves more profound investigation.


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Differential effects of coping in mental disorders: A prospective study in psychiatric outpatients