Life event stress and psychiatric illness

The idea that life stress can cause illness is supported more by faith than scientific evidence so concluded Dohrenwend & Dohrenwend (1978) in a recent review. In regard to physical illness Andrews & Tennant (1978) have drawn attention to recent large-scale prospective studies which failed to find an association between life event stress and physical illness. Presumably the uniformly positive association between life stress and illness shown in retrospective studies must be due to problems in the recall of events by sick people. A life crisis, whether due to a single catastrophe or a surfeit of ordinary life events, may produce demoralization and dependence on medical services but has not been shown to cause the onset of physical disease. In animals, environmental stimuli that produce prolonged arousal and changes in hormonal and immune competence levels have resulted in physical illness. These mechanisms exist in humans but the human ability to recruit social support, defend intrapsychically and cope environmentally may limit arousal to non-pathogenic levels. In psychiatry the picture is more complicated. Studies of disasters show that when the psychological stress is sufficiently severe, virtually everybody decompensates and becomes demoralized, dependent and identifiable as a psychiatric casualty. Such disasters are rare and the more relevant issue is whether the trials and tribulations of everyday life contribute to psychiatric illness. Belief in such an association is ubiquitous: but the problems in demonstrating predictive associations are legion. Five years ago it appeared from the pages of this Journal (Brown et al. 1973 a, b; Jacobs et al. 1974) and from other publications (Brown, 1974a, b; Paykel, 1974) that 2 independent groups of investigators had succeeded in this task. Which life events are to be regarded as stressful? In London Brown's group identified as events changes in life circumstances occurring to the subject; and role and health changes occurring to the subject, his relatives and household members. Events were carefully dated, the context or circumstances surrounding the event noted and event occurrence verified by interviewing relatives. The research team, taking the patient's individual circumstances into account but not his own reaction to the event, then made judgements as to the threat such an event would pose to the average person. In this way Brown hoped to reduce the principal bias confounding retrospective studies, the 'effort after meaning' as patients sought reasons to explain their illness. Given that the identification and scaling of such events could be reliably achieved, then the Brown technique had the potential advantage of being able to accommodate the infinite combinations of event and circumstance that constitute the predicaments of human existence. An apparently more limited methodology was developed by the New Haven group (Paykel, 1974). They used a check list of some 60 items to ascertain events occurring in the 6 months prior to illness. Events were then analysed by area of activity (changes in health, work, family, etc.), by whether they represented entrances or exits to the person's social field, and by whether they were events of a socially desirable or undesirable nature. For some studies the events were weighted as to 'how upsetting the event would be to the average person' and the weighted scores of events experienced were summed to give an estimate of the life event stress impinging on an individual. Despite the methodological differences the findings of the 2 groups are remarkably similar.