The Iowa 500: precipitating factors in schizophrenia and primary affective disorder

Does stress play a significant role in bipolar disorder? A meta-analysis

BACKGROUND

There is evidence that stressful life events (LE) play a crucial role in the etiology of bipolar affective disorder (BD). However, primary studies, as well as narrative reviews, have provided mixed results. The present meta-analysis combined and analyzed previous data in order to address these inconsistencies.

METHOD

Forty-two studies published in 53 records were identified by systematically searching MEDLINE, PsychINFO, and PSYCHINDEX using the terms "bipolar disorder" OR "manic-depressive" OR "bipolar affective disorder" OR "mania" AND "stress" OR "life event" OR "daily hassles" OR "goal attainment". Then, meta-analyses were conducted.

RESULTS

Individuals diagnosed with BD reported more LE before relapse when compared to euthymic phases. They also experienced more LE relative to healthy individuals and to physically ill patients. No significant difference in the number of LE was found when BD was compared to unipolar depression and schizophrenia.

LIMITATIONS

When interpreting the present meta-analytic findings one should keep in mind that most included studies were retrospective and often did not specify relevant information, e.g., if the LE were chronic or acute or if the individuals were diagnosed with BD I or II. We could not entirely rule out a publication bias.

CONCLUSION

The present meta-analyses found that individuals with BD were sensitive to LE, which corroborates recent theoretical models and psychosocial treatment approaches of BD. Childbirth, as a specific LE, affected individuals with BD more than individuals with unipolar depression. Future studies that investigate specific LE are warranted.

Comparison of precipitating factors for mania and partial seizures: Indicative of shared pathophysiology?

OBJECTIVES

Mania in bipolar disorder (BD) and partial (focal) seizures (PS) arising from the temporal lobes, have a number of similarities. Typically, a chronic course of the disorders is punctuated by acute illness episodes. Common features of episodes may include sensory, perceptual, cognitive and affective changes. Both respond to anticonvulsant treatment. Common mechanisms imputed include neurotransmitters and kindling processes. Further investigation may improve understanding of the occurrence of both mania and PS, casting light on the relevance of temporal lobe mediated processes and pathology. One avenue of investigation is to compare aetiological factors and determine the extent of overlap which may indicate shared brain localization or pathophysiology. Aetiology includes predisposing, precipitating or perpetuating factors. This paper examines the literature on precipitating factors of mania, first or subsequent episode, and of PS in diagnosed epilepsy, which is the second or subsequent seizure, to identify the extent and nature of their overlap.

METHOD

Narrative review based on a literature search of PubMed and Google Scholar.

RESULTS

Precipitating factors for both mania and PS were stress, sleep deprivation, antidepressant medication and, tentatively, emotion. For mania alone, goal-attainment events, spring and summer season, postpartum, and drugs include steroids and stimulants. For PS alone, winter season, menstruation and specific triggers in complex reflex epilepsies. Those not substantiated include lunar phase and menopause. A wide range of chemicals may provoke isolated seizures but by definition epilepsy requires at least two seizures.

CONCLUSIONS

The overlap of precipitating factors in mania and PS imply that common brain processes may contribute to both, consistent with findings from neuroscience research.

A cognitive vulnerability-stress perspective on bipolar spectrum disorders in a normative adolescent brain, cognitive, and emotional development context

Why is adolescence an "age of risk" for onset of bipolar spectrum disorders? We discuss three clinical phenomena of bipolar disorder associated with adolescence (adolescent age of onset, gender differences, and specific symptom presentation) that provide the point of departure for this article. We present the cognitive vulnerability-transactional stress model of unipolar depression, evidence for this model, and its extension to bipolar spectrum disorders. Next, we review evidence that life events, cognitive vulnerability, the cognitive vulnerability-stress combination, and certain developmental experiences (poor parenting and maltreatment) featured in the cognitive vulnerability-stress model play a role in the onset and course of bipolar disorders. We then discuss how an application of the cognitive vulnerability-stress model can explain the adolescent age of onset, gender differences, and adolescent phenomenology of bipolar disorder. Finally, we further elaborate the cognitive vulnerability-stress model by embedding it in the contexts of normative adolescent cognitive (executive functioning) and brain development, normative adolescent development of the stress-emotion system, and genetic vulnerability. We suggest that increased brain maturation and accompanying increases in executive functioning along with augmented neural and behavioral stress-sensitivity during adolescence combine with the cognitive vulnerability-stress model to explain the high-risk period for onset of bipolar disorder, gender differences, and unique features of symptom presentation during adolescence.

Stress, the hippocampus and the hypothalamic-pituitary-adrenal axis: implications for the development of psychotic disorders

OBJECTIVE

The experience of stress is commonly implicated in models of the onset of psychotic disorders. However, prospective studies investigating associations between biological markers of stress and the emergence of psychotic disorders are limited and inconclusive. One biological system proposed as the link between the psychological experience of stress and the development of psychosis is the Hypothalamic-Pituitary-Adrenal (HPA) axis. This paper summarizes and discusses evidence supporting a role for HPA-axis dysfunction in the early phase of schizophrenia and related disorders.

METHOD

A selective review of psychiatric and psychological research on stress, coping, HPA-axis, the hippocampus and psychotic disorders was performed, with a particular focus on the relationship between HPA-axis dysfunction and the onset of psychotic disorders.

RESULTS

Individual strands of past research have suggested that the HPA-axis is dysfunctional in at least some individuals with established psychotic disorders; that the hippocampus is an area of the brain that appears to be implicated in the onset and maintenance of psychotic disorders; and that an increase in the experience of stress precedes the onset of a psychotic episode in some individuals. Models of the onset and maintenance of psychotic disorders that link these individual strands of research and strategies for examining these models are proposed in this paper.

CONCLUSIONS

The current literature provides some evidence that the onset of psychotic disorders may be associated with a higher rate of stress and changes to the hippocampus. It is suggested that future research should investigate whether a relationship exists between psychological stress, HPA-axis functioning and the hippocampus in the onset of these disorders. Longitudinal assessment of these factors in young people at 'ultra' high risk of psychosis and first-episode psychosis cohorts may enhance understanding of the possible interaction between them in the early phases of illness.

The psychosocial context of bipolar disorder: environmental, cognitive, and developmental risk factors

In this article, we review empirical research on the role of individuals' current environmental contexts, cognitive styles, and developmental histories as risk factors for the onset, course, and expression of bipolar spectrum disorders. Our review is focused on the following over arching question: Do psychosocial factors truly contribute risk to the onset, course, or expression of bipolar disorders? As a secondary issue, we also address whether the psychosocial risks for bipolar disorders are similar to those for unipolar depression. We begin by discussing the methodological requirements for demonstrating a psychosocial risk factor and the challenges posed by bipolar spectrum disorders for psychosocial risk research. Next, we review the extant studies on the role of recent life events and supportive and non-supportive social interactions (current environment) in bipolar disorders, as well as psychosocial treatments designed to remediate these current environmental factors. We then review the role of cognitive styles featured as vulnerabilities in theories of unipolar depression as risk factors for bipolar disorder alone and in combination with life events, including studies of cognitive-behavioral therapies for bipolar disorder. Finally, we review studies of parenting and maltreatment histories in bipolar disorders. We conclude with an assessment of the state of the psychosocial risk factors literature in bipolar disorder with regard to our guiding questions.

Social influences on bipolar affective disorders

The impact of psychosocial adversity on the onset and course of bipolar disorder has been assessed in studies that have relied on methods of eliciting life event histories and evaluating family atmosphere. The results of life event studies have been inconsistent, perhaps because the relationship between bipolar disorder and major stress is only pronounced in first or early episodes. If this is so, this phenomenon itself invites explanation, whether in social or biological terms. The two studies to data of family atmosphere suggest an association between high expressed emotion and relapse. The relationship between psychosocial stress and bipolar disorder requires further and more detailed research.

Stressful life events and schizophrenia. II: Conceptual and methodological issues

Research on the relationship between stress and schizophrenia is fraught with conceptual and methodological problems. These problems include issues related to the nature and measurement of stress, the likelihood of reciprocal influences between stress and symptoms, and the adequate assessment of symptoms. Several recommendations are made regarding future research in this area. These include using multiple and broadly based measures of different types of stressors and symptoms, greater use of truly prospective research designs, and the evaluation of the effects of interventions specifically designed to reduce stress in patients who suffer from schizophrenia.

Life events and psychosis. Initial results from the Camberwell Collaborative Psychosis Study

Data from the Camberwell Collaborative Psychosis Study were used to examine the proposition that there is an excess of life events preceding the onset of psychoses of all types. Of 97 patients from the study who had episodes within the past year that were datable, 51 had developed psychotic symptoms from an essentially symptom-free state, 29 had been suffering only from neurotic symptoms, and 17 had experienced a marked exacerbation of psychotic symptoms. DSM-III diagnoses were collapsed into three major groups: 51 cases of schizophrenia; 31 cases of mania; and 14 cases of depressive psychosis. Life-event histories were taken for the six months before onset, and when these were compared with equivalent histories from a psychiatrically healthy sample from the local general population, there was a significant excess of life events, particularly in the three months before onset of psychosis. This was apparent in all groups, and remained even when events were restricted to the independent category. The excess of events began rather earlier than has been found in previous studies. In our view, this study provides some of the strongest evidence for a link between life events and the emergence of psychotic symptoms.

Life events and relapse in schizophrenia. A one year prospective study

Results from a one year prospective study of a relationship between major and minor life events (all other events), and relapse in twenty-two schizophrenic (DSM III-R) patients are reported. Seven (33%) patients relapsed during the one year of follow-up. Relapsed patients had experienced significantly more independent major and minor life events during the one year compared to non-relapsed patients. The independent events experienced by the relapsed patients occurred twice as often in the three month period prior to the relapse as compared to any other period among the relapsed, or the non-relapsed patients. These findings are discussed in the context of the prospective design of this study and the inclusion of minor as well as major events.

Life events and relapse in bipolar disorder: the impact of a catastrophic event

The literature on life events and the precipitation of bipolar disorder is reviewed. The authors describe an unexpected increase in bipolar relapses in a Lithium Clinic following a catastrophic life event, a hurricane, and contrast the patients who relapsed with an age and sex matched control of bipolars who did not. Though retrospective, the study avoids the question of the independence of life events. The results suggest that certain bipolar patients, especially those recently unstable, may be more vulnerable to the impact of life events.

Live events and schizophrenic episodes

Studies of live events and schizophrenia are few. Most have such methodological limitations that make any causal interpretation of their findings impossible. Of the three studies with appropriate methodology and controls, Brown and Birley (1968) found very recent life events trigger onset, Leff et al. (1983) found events were capable of precipitating relapse, under certain restricted circumstances, while Jacobs and Myers (1976) found independent events appear to have no significant effect. The widely held view that life events can precipitate schizophrenic episodes may be supported by our own clinical impressions; it is as yet not well supported by empirical data. Future research should perhaps focus on other definitions of these psychoses, such as is now embraced by DSM-III. Perhaps then a relation between stressful events and some of the non-depressive functional psychoses might be demonstrated.

Life events and response to antidepressants

The present study examined the relationship of life events and response to tricyclic antidepressants among 80 outpatients with unipolar, primary depressions. Participants were randomly assigned to receive either amitriptyline or amoxapine. Events occurring in either the two or 12 months prior to starting treatment (antecedent events) were unrelated to antidepressant response. However, events occurring during the treatment period itself (concurrent events) were significantly related to tricyclic response. Patients evidencing the poorer response reported almost three times as many concurrent events as the more improved patients. A poorer tricyclic response was associated in particular with concurrent events which were undesirable, health related, and perceived as being outside of the patient's own control. It was suggested that the continuing occurrence of stressor events probably interferes with treatment efforts and, therefore, it may be important for the therapist to pay careful attention to the ongoing life stresses of the depressed patient.

The Iowa 500: field work in a 35-year follow-up of depression, mania, and schizophrenia

This paper reports a follow-up and family study being carried out at the University of Iowa College of Medicine on primary affective disorders and schizophrenia in patients hospitalized thirty-five years ago. The purpose of this project is to obtain objective data to shed light on our understanding of these two major functional psychoses -- their diagnostic validity, clinical features, course and outcome, heterogeneity, life histories, related illnesses and characteristics of familial association. This research started with 525 patients selected from inpatients consecutively admitted to the Iowa Psychopathic Hospital between 1934 and 1944, and with a stratified random sample of 160 surgical patients admitted to the University General Hospital during the same period. A specially designed structured interview form -- the Iowa Structured Psychiatric Interview (ISPI) -- is used to follow up all living index patients, and as many of their living first-degree relatives as possible. At this time, over one-third of the estimated total study population of three thousand patients and relatives have been personally interviewed, and the preliminary findings are reported here.