Millennial reviewThe evolution of life events research in psychiatry
Introduction
Views on the place of life stress in the genesis of psychiatric disorders are implicit in early writings on mental illness, but systematic research is comparatively recent. This paper will review some aspects of its modern evolution.
The events of two world wars with experience of ‘shell shock’ in the first and better recognition of the nature and consequences of battle stress in the second, left no doubt as to the consequences of severe stress. Study of the consequences of the kinds of stress which lay more in the realm of common experience, and effects on the illnesses of peacetime were slower to develop.
A good deal of the work in the first 20 years after the Second World War, and the precursors of modern research in life stress and psychiatric disorder, lay in physical disorder. This work was influenced by studies of somatic and endocrine consequences of stress in animals, including those of Cannon (1929) and Selye (1956). A conference of the Association for Research in Nervous and Mental Diseases on the topic of Life Stress and Bodily Disease brought together much early work (Wolff et al., 1950), and gave impetus to further research. Later two other conferences, in Beito, Norway in 1972 (Gunderson and Rahe, 1974), and in New York in 1973 (Dohrenwend and Dohrenwend, 1974) had similar effects on the psychiatric field.
Two major studies were undertaken by Harold Wolff and Lawrence Hinkle at Cornell University Medical College. In the first, a group of telephone operators in New York were studied regarding illness over a 20-year period, using medical sickness records and interview. In the second, a similar procedure was used for blue collar workers involved in installation and repair of telephone equipment. Findings in both groups were similar (Hinkle and Wolff, 1958). Illnesses were not randomly distributed but particularly affected certain individuals, and occurred in clusters. Some of these clusters appeared related to stressful circumstances.
A major influence on this work lay in the views of Adolph Meyer, Head of the Department of Psychiatry at Johns Hopkins University. He had earlier introduced the ‘life chart’ as a way of charting life history, psychiatric and physical illnesses and stressful circumstances, and he emphasised that various life events within common experience could be an important part of the aetiology of a disorder (Meyer, 1951).
Section snippets
Lists, schedules and interviews
Systematic research required some more systematic way of recording life event experience. An early contribution, again in the field of physical and psychosomatic disorder, was the Schedule of Recent Experience, derived by Thomas Holmes and co-workers (Hawkins et al., 1957). This was a list of life events, administered as a self report questionnaire and used in retrospective studies of tuberculosis, heart disease, skin disease, hernia and pregnancy (Rahe et al., 1964).
A powerful fillip to this
Retrospective studies of clinical samples
The modern era of life event studies was ushered in during the late 1960s by the first studies using comprehensive interviews for events, and making comparisons with control samples from the general population. Earlier there had been a few studies in depression not using systematic interviews, and often employing medical patient control groups, not really suitable for such studies in view of the likely impact of stress on consultation or referral to hospital for medical disorders.
In New Haven,
Other aspects of depression
For depression, issues have been bound up with older debates about classification and endogenous versus reactive depression. In general the idea of reactive and endogenous depressives as separate groups with separate symptom patterns has not survived well (Brown et al., 1979, Paykel et al., 1984). Depressions vary in the extent to which they are preceded by life stress, but this does not relate well to symptom pattern. It may be that a group of recurrent severe depressives have less stress (
Magnitude of causative effect
The early years of controlled life events research saw a vigorous debate as to whether they mattered or were lesser precipitants with other factors being the true causes. These debates came from earlier views, entrenched in psychiatry, between those supporting psychological causation of disorder and those assigning primacy to constitutional, genetic and biological causes.
Efforts to quantify causation arose as a way of resolving this problem. Brown et al. (1973b) devised the ‘brought forward
Prospective studies and specific events
It is surprising how little impact on the psychiatric life event literature has been made by longitudinal studies of consequences of specific events. The prospective study in which all subjects undergoing a specific event are followed up is an excellent strategy for examining the proportions of subjects affected adversely by an event, and effects of modifying factors. Among a number of events which have been studied in this manner are bereavement (Lichtenstein et al., 1998, Chen et al., 1999),
Social support and other modifying factors
The potential importance of modifying factors has already been referred to. A major contribution to this aspect occurred comparatively early with the studies of Brown, Harris and co-workers in Camberwell and in the Hebrides. In Camberwell, whether or not a life event resulted in depression was considerably affected by four ‘vulnerability factors’ — presence of several young children at home, absence of a confidant, lack of employment, and early loss of mother (Brown and Harris, 1978). In a
What causes a life event
As thinking in this area becomes more subtle, and the pathways to disorder are acknowledged to be more complex, a theme for the 1990s has become the origin of life events themselves. Hammen (1991) studied dependent events in the Brown sense, and as expected found them more common in unipolar depressives than normal controls. There were no differences for independent events, providing some validation of the concept. Harkness et al. (1999) found dependent events more common in recurrent
The next steps in life event research
After 30 years of study, the main findings of retrospective controlled studies of life events at onset and recurrence of psychiatric disorders have become clear. Psychiatric disorders have been well studied. Although the story started in the 1950s with somatic disorders, psychosomatic disorders and what would now be called illness behaviour, there have still been comparatively few studies in this area using good life event methodology. Such studies would still be worthwhile.
The focus of event
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