notebook with drawing of head and words coping with stress

In recent years, the importance of managing stress with effective coping skills has gained traction in the general population, and among people with psychosis, experts consider managing stress with practical coping skills an essential part of preventing relapse.

In fact, tt’s difficult to talk about behavioral health for very long without addressing the topic of stress.

On the positive side, the ability to deal with stress in a productive manner can be a sign of good mental health. On the less-than-positive side, unmanaged stress is a risk factor for anxiety, depression, substance abuse, and myriad other conditions.

For people who are recovering from psychotic disorders, stress can pose a particularly difficult challenge. According to recent research, certain types of stress can trigger a variety of negative outcomes, including social withdrawal and a relapse into psychosis.

What Is Psychosis?

Before we delve into how stress, social withdrawal, and the absence of coping skills can lead to psychosis relapse, let’s take a moment to review what we mean when we say psychosis,

Psychosis is a disorienting and distressing experience that is characterized by impairments in how a person perceives their environment and interacts with others. Psychotic episodes may include five types of symptoms:


Fixed, unchangeable beliefs that are easily disproven or that have no basis in reality.


Seeing, hearing, or otherwise sensing things that don’t exist.

Disorganized thinking or speech:

Inability to communicate one’s thoughts in a comprehensible manner.

Disorganized or abnormal behaviors:

Dressing or acting in a bizarre manner, holding one’s body in strange positions, and other potentially disturbing actions.

Negative symptoms:

Lack of facial expressiveness, speaking in a flat or monotone voice, and exhibiting little to no interest in interacting with other people.

Some people who struggle with psychosis will experience all five of the symptoms listed above, while others will experience just a few. Delusions and/or hallucinations are the most common psychotic symptoms.

Psychosis is sometimes (but by no means always) a symptom of a mental health disorder. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) includes entries for the following psychotic disorders:

  • Schizophrenia
  • Schizoaffective disorder
  • Schizophreniform disorder
  • Delusional disorder
  • Brief psychotic disorder
  • Substance/medication-induced psychotic disorder
  • Psychotic disorder due to another medical condition

Psychosis may also result from causes such as overwhelming stress, substance abuse, sleep deprivation, extreme hunger, and untreated trauma.

Experts estimate that the lifetime prevalence of psychotic disorders is 1.5%-3.0%. With a current U.S. population of about 335 million people, this means that 5-10 million Americans are likely to have a psychotic disorder at some point in their lifetime.

Studies also indicate that many more people will experience psychotic episodes that are not related to a primary psychotic disorder.

The Influence of Stress & Social Withdrawal

Psychosis is treatable. When a person receives the type and level of care that best align with their needs, they can regain control of their thoughts and behaviors. Depending on what caused a person to struggle with psychosis, effective treatment may involve various medications as well as multiple forms of therapy.

However, as is the case with most mental health concerns, psychotic disorders are chronic conditions. This means that they cannot be cured. Instead, the goal of treatment is to reduce distress and empower the individual to better manage their symptoms.

An important part of treatment for psychosis is helping people learn how to identify triggers, which are situations or circumstances that could undermine their recovery and push them into relapse (or a recurrence of the psychosis). This is an essential area of focus, as studies indicate that about two-thirds of people who receive care for psychosis will relapse.

In April 2023, the German journal Schizophrenia published a systematic review of prior research into the link between two potential triggers (stress and social withdrawal) and psychosis relapse.

Notable Features: Sample Size and Time Period

  • The review was conducted by an international team of researchers from King’s College London, Saudi Arabia’s Princess Nourah bint Abdulrahman University, and the UK’s NHS Foundation Trust.
  • The review team began with a pool of 460 eligible studies, which they narrowed down to 16 for their review.
  • The 16 studies in the review were conducted in eight countries and published between 1971 and 2021.
  • The studies involved a total of 2,248 adult subjects (aged 18-65), all of whom had some form of psychosis.

The research team noted that prior studies have indicated that stress can have a powerful influence on relapse. However, these studies did not clarify if the most influential factor was environmental (exposure to excessive stress) or genetic (a heightened sensitivity to stress). They also set out to determine how social withdrawal in the aftermath of stress may impact a person’s risk for relapse.

Notable Results: The Impact of Psychosocial Stress on Relapse

  • 10 of the 13 studies that focused on stress found links between all forms of psychosocial stress and relapse, regardless of which type of psychotic disorder a person had.
  • Interpersonal conflicts and stress due to moving home were strongly associated with relapse.
  • People with chronic schizophrenia were more likely to relapse after experiencing stressors related to social adjustments, while those with acute schizophrenia were more likely to be negatively impacted by conflicts with friends or family members.
  • All studies that assessed the impact of social withdrawal found that it increases a person’s risk for relapse.
  • None of the studies confirmed a relationship between sensitivity to stress and relapse.

In addition to being negatively impacted by stress and withdrawal, people with psychosis also deal with greater amounts of stress than do those who have no history of mental illness, the research team found.

“Individuals with psychosis tend to experience high levels of psychosocial stress and social withdrawal, and these appear to increase the risk of psychosis relapse.” they wrote. “In addition, the reviewed literature showed that individuals with psychosis experience a higher level of psychosocial stress and social withdrawal compared to healthy controls.”

The Benefit of Positive Stress Management and Coping Skills: Relapse Prevention

Two years before the release of the review that we discussed in the previous section, the International Journal of Mental Health Nursing published a related study from China.

The Chinese study evaluated the impact of stress and coping skills on 248 people who had received outpatient treatment for schizophrenia. Within this population, 106 subjects were in the relapse group and 146 were in the non-relapse group

The Chinese research team noted that stress is often a precursor to relapse – but they added the observation that merely reducing exposure to stress “is inadequate to reduce the risk of relapse.”

To limit the likelihood of relapse, their research indicated, it is important for people to develop the right types of coping skills. For the purposes of this study, they divided the various forms of coping skills into two categories:

Positive Coping Skills

  • This category included activities such as optimistic thinking, increased participation in social activities, and engaging in productive hobbies such as exercising.

Negative Coping Skills

  • The research team did not provide specific examples for this category. However, other sources have identified escape, resignation, withdrawal, and avoidance as examples of negative coping strategies.

The research team assessed their subjects using three tools. They used the Scale for the Social Readjustment Rating, the Brief Psychiatric Rating Scale, and the Simplified Coping Style Questionnaire.

These assessments yielded the following results:

  • The team found “a significant positive association” between stressful life events and a relapse of schizophrenia symptoms.
  • People who employed positive coping skills in response to stressors had a lower risk of relapse.
  • People who used negative coping skills had a higher risk of relapse.

Not only do positive coping skills limit the likelihood of relapse, but they may also promote improved future outcomes, the researchers found.

“When patients begin to take the initiative to enrich their lives, the risk of relapse is reduced,” they wrote. “Furthermore, maintaining the stability of the disease can improve the quality of life and reduce the number of hospitalizations, thereby generating a belief in positive coping.”

Conversely, negative coping skills can cause immediate harm as well as increase a person’s risk for additional damage.

“Failure to accept the disease and feelings of hopelessness for the future are also likely to exacerbate symptoms and increase the risk of relapse,” the researchers wrote. “Once the patients experience relapse, the negative experience will likely send them into a cycle of negative coping.”

Implications for Treatment

Stress, social withdrawal, and coping skills are far from the only factors that can influence the severity of a person’s struggles with psychosis. But treatment professionals can address them with proper support and care.

Learning how to make better decisions and limit one’s exposure to certain stressors can be an important element of care for people who have been struggling with psychotic disorders and other complex mental health concerns. But expecting to live a stress-free life is an unrealistic expectation for anyone. That’s why developing effective stress management and social coping skills can help reduce risk of relapse to psychosis.

At Crownview Psychiatric Institute, we know we can’t control what happens to our patients after they transition out of our center. Therefore, we make a concerted, ongoing effort to prepare them to respond to difficult situations in the healthiest and most productive manner.

We address stress management and other important life skills in both the therapeutic and educational components of our programming. We also promote healthy interpersonal interactions via our dynamic community-like treatment environment and our comprehensive wraparound services.

To learn more about our services for adults who have schizophrenia, schizoaffective disorder, and other psychotic disorders, please contact us. We look forward to answering your questions and helping you determine if CPI is the ideal place for you or your loved one.