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D.S.W. Converted to Ph.D PSYCHOSOCIAL STRESSORS AND MAJOR DEPRESSION, SCHIZOPHRENIA, AND SCHIZOPHRENIFORM DISORDER Janet B.W. Williams Submitted in partial fulfillment of the requirements for the degree of Doctor of Social Welfare in the School of Social Work COLUMBIA UNIVERSITY 1981 D.S.W. converted to Ph.D. in 2011 ,",- . JANET B.W. WILLIAMS ALL RIGHTS RESERVED ABSTRACT PSYCHOSOCIAL STRESSORS AND MAJOR DEPRESSION, SCHIZOPHRENIA, AND SCHIZOPHRENIFORM DISORDER JANET B.W. WILLIAMS This study explored the relationship between the se- verity and types of psychosocial stressors and three major mental disorders. The data were derived from the field trials of the third edition of the American psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-III), in which over 12,000 patients from allover the country were evaluated by over 500 clinicians. Two hundred forty-seven patients with Major Depression and 247 with Schizophrenia were randomly selected for this study, along with all 112 patients given the diagnosis of Schizophreniform Disorder, a disorder similar to Schizo- phrenia except for its brief duration. The number of psychosocial stressors recorded by the evaluating clinician for each subject was examined, and each stressor was classified according to whether it represented an entrance into or exit from the social field of the sub- ject, whether or not it was desirable, whether or not its 'occurrence had been under the control of the subject, the number of Life Change Units it entailed, and what area of the subject's life it affected. These variables were then compared across diagnostic groups, for individuals with and without associated Personality Disorders. In addi~ton, for each diagnostic group, the relationship between the subjects' highest mean level of adaptive functioning and the mean severity of their psychosocial stressors was exam­ ined, using the multiaxial system of DSM-III. Major findings that replicated those reported in the literature include that a greater proportion. of individuals with Major Depression were reported to have experienced a greater number of stressors, undesirable events, entrances, and uncontrollable events, than individuals with Schizo­ phrenia. Significant new findings include that, for Schizo­ phrenia, the highest level of adaptive functioning in the past year and level of severity of stressors experienced prior to episode onset are positively correlated, while for Major Depression these variables are negatively correlated. The results for Schizophreniform Disorder are equivocal, with similar results to Major Depression for some stressor dimensions, and midway between the other two groups on others. The implications for social work practice of these findings and further study of life events are great, for primary, secondary, and tertiary prevention of mental illness. TABLE OF CONTENTS Page LIST OF TABLES .....•..........•.......................• iii ACKNOWLEDGEMENTS. • . • . • . • . • . • • • . • . v CHAPTER I. THE RESEARCH PROBLEM.......................... 1 Background. 1 Stressful Life Events and Mental Health ..... 4 Stressful Life Events and Social Work ....... 6 II. THE LITERATURE, OBJECTIVES, AND HyPOTHESES .... 11 The Literature .............................. 11 Introduction. .. 11 Stressful Life Events and Depression ...... 12 Stressful Life Events and Schizophrenia ... 28 Stressful Life Events, Depression, and Schizophrenia ........................... 36 Dis ell S s i on. .. 42 Methodologic Considerations ................. 46 Objectives of This Study ..•..............•.. 55 Specific Hypotheses to be Tested ............ 57 III. STUDY DESIGN AND METHOD ....................... 60 The Larger Study: The DSM-III Field Trials .. 60 The Sample.................................. 81 Selecting and Defining the Stressor Dimen- S1ons. .. 87 Construction of the Area of Life Scale (ALS) .....•...........•...............•... 100 Coding the Stressors ........................ 103 Reliability of the Ratings .•.........•...... 107 IV. DATA ANALYSIS ......•.......................... 116 Introduction ................................ 116 The Subjects ................................ 116 The Clinicians .............................. 121 Axis IV: Severity of Psychosocial Stressors. 123 Axis V: Highest Level of Adaptive Function- ing Past year •••...•...................... 126 i Page Axis IV and Axis V .......................... 128 Number of Stressors •••••••••••••••.•.•.••••• 131 Desirability of Stressors •••.•...•••.••••.•. 133 Entrances/Exits ....... "...................... 139 Controllability of Stressors •..•..•...•••••• 145 Life Change Units •••••.••..•..•••..•..••••.• 149 Area of Life Scale (ALS) .•••••...•....•••••. 153 Personali ty Disorders ••.......••....••.•..•. 157 v. DISCUSSION.· .....•...•......................... 167 VI. CONCLUSION .................................... 191 APPENDICES .................................... 196 A. DSM-III Diagnostic Criteria for Major Depression, Schizophrenia, and Schiz­ ophreniform Disorder ....•.••.••••..•.•• 196 B. Diagnostic Report Form (DIRE) .....•..•..• 201 C. DSM-III 1/15/78 Draft Text for Axis IV Severity of Psychosocial Stressors ....• 203 D. DSM-III Draft Text for Axis V Highest Level of Adaptive Functioning Past Year ................................... 206 E. Area of Life Scale (ALS) .•.•••..•••.••••• 207 RF.FERENCES •••••••••••••••••••••••••••••••••••• 216 ii LIST OF TABLES Page 1. Summary of Studies of Life Events ...........•....• 44 2. Mean Kappa Coefficients of Agreement on Broad and Specific Categories (Summarized from Six Studies Using DSM-I and DSM-II} ................ 66 3. Kappa Coefficients of Agreement for Axes I and II DSM-III Diagnostic Classes for Adults (18 and Older)..................................... 69 4. DSM-III Kappa Coefficients of Agreement for Adults (18 and Older) .......................... 73 5. Reliability of Ratings on Axes IV and V for Adults (18 and Older) .......................... 77 6. Age-Sex Frequency Distribution of the Entire Field Trial Sample (Phase One) for Major Depression and Schizophrenia ........•..... ~ .... 85 7. Age-Sex Distributions by Diagnostic Group of Study Subjects ................................. 88 8. Social Readjustment Rating Scale .................. 97 9. Percentages of Stressors Given Various Ratings Within Each Stressor Dimension (Total N of Stressors = 786) .............................•. 106 10. Agreement and Disagreement on Desirability of Stressors (Reliability Study) .................. 113 11. Agreement and Disagreement on Entrances/Exits Dimension (Reliability Study) ...•.............. 114 12. Agreement and Disagreement on Controllability Dimension (Reliability Study) ...•.............. 115 13. Ethnic-racial Background Distribution of Study Subjects ....................................... 119 14. Distribution of Study Subjects by Clinical Setting ........................................ 120 15. Percentage of Subjects in Each Diagnostic Group Receiving Each Axis IV Severity Rating ......... 125 16. Percentage of Subjects in Each Diagnostic Group Receiving Each Axis V Level .................... 127 17. Pearson Product-moment Correlation Coefficients and Their Levels of Significance for Axis IV and Axis V for Each Diagnostic Group ........... 130 18. Number of Stressors Recorded for Subjects in Each Diagnostic Group .•..................•......•... 132 19. Mean Number of Psychosocial Stressors Reported by Each Diagnostic Group ..•.....•..•.•...•..... 134 20. Number of Subjects in Each Diagnostic Group Experiencing Desirable and/or Undesirable Stressors ...................................... 136 iii Page 21. ALS Categories Rated as Desirable •......•....•...• l38 22. Number of Subjects in Each Diagnostic Group Experiencing Entrances and Exits .....•...••.•.. l4l 23. ALS Categories Rated as Entrances and Exits ......• l43 24. Number of Subjects in Each Diagnostic Group Experiencing Controllable and/or Uncontrollable Stressors ...................................... 146 25. Mean Number of Life Change Units for Each Diag- nostic Group ................................... 151 26. Percentage of Subjects in Each Diagnostic Group Experiencing Various Levels of Life Change Units .......................................... 154 27. Number of Subjects in Each Diagnostic Group With Stressors in Each ALS Category ................. l56 28. Proportion of Subjects in Each Diagnostic Group Also Diagnosed as Having a Personality Disorder ....................................... 158 29. Mean Axis V Ratings for Subjects With and Without Personality Disorders in Each Diagnostic Group.160 30. Mean Axis IV Ratings for Subjects With and Without Personality· Disorders in Each Diagnostic Group.l62 31. Number of Subjects in Each Diagnostic Group With and Without Personality Disorders, With Only Desirable and Only. Undesirable Events ....•..... 163 32. Number of Subjects in Each Diagnostic Group With and Without Personality Disorders, With Only Entrances and With Only Exits .................. 164 33. Number of Subjects in Each Diagnostic Group With and Without Personality Disorders, With Only Controllable and With Only Uncontrollable Stressors ...................................... 165 iv ACKNOWLEDGEMENTS I am fortunate to have received the help and advice of many people. First of all, Dr. Martin Whiteman, my ad­ visor, provided much-needed encouragement and advice at crucial points along the way. Bob Spitzer,· the Principal Investigator of the research project on which this study is based, and former Chair
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