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Stressful Life Events, Social Class and Symptoms of Schizophrenia Bernard J

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Stressful Life Events, Social Class and Symptoms of Schizophrenia Bernard J Original Contributions Stressful Life Events, Social Class and Symptoms of Schizophrenia Bernard J. Gallagher III 1, Brian J. Jones 1, Mariana Pardes 1 Abstract We test to see if severe stressful life events precede onset of specific symptoms of schizophrenia. Our analyses extend to possible variations in the effect by socioeconomic status (SES) of origin. The medical records of 431 schizophrenic patients were categorized into negative and positive subtypes by application of SANS, SAPS and PANSS scales. SES was bifurcated into low-SES and high-SES groups. Stressful life events were classified into four domains. The study vari- ables were tested by the use of chi-square analysis. Our results show that there is an elevated rate of positive symptoms among low-SES patients who underwent a stressful life event before symptom onset. Significance is confirmed with an X2 value of 5.418, p=.020. The finding does not hold true for high-SES patients and is not related to type of stressful life event. Thus, we conclude that environmental stressors frequently precede onset of positive symptoms of schizophrenia. This is only true for patients of low SES of origin. We hypothesize that low-SES patients have a heightened reactivity to stressors, a reactivity that is incubated by the human toll of impoverishment. Key Words: Positive Symptoms, Schizophrenia, Life Stressors, Social Class Introduction fects of a biological vulnerability to schizophrenia and envi- The genesis of schizophrenia appears to be multifacto- ronmental precipitants such as stressful life events (6-9). Life rial and best explained by a holistic approach that accounts events are considered to “trigger” onset or exacerbation of for the significance of interactions between biological un- the symptoms of schizophrenia (10-12). derpinnings and psychosocial factors (1, 2). Both of these The proposition that there is an excess of major life events variables—biological and psychosocial factors—are thought preceding psychosis has been reported in a number of stud- to influence the onset and course of the psychosis (3, 4). This ies (13, 14, 6). Likewise, minor stressors and “daily hassles” is the basic proposition of the diathesis-stress theory (5), a may sometimes be a significant predictor of later psychotic conceptual model that emphasizes the combined causal ef- symptoms (15-18). Additionally, research suggests that the typical timeframe for the initial episode of psychosis is dur- 1Department of Sociology & Criminology, Villanova University, ing late adolescence or early adulthood (19). Adolescence Villanova, PA has been recognized as a developmental period that places Address for correspondence: Bernard Gallagher, PhD, Department of unique demands on social and psychological function- Sociology & Criminology, Villanova University, 800 Lancaster Avenue, ing (20-23) and is also correlated with biological changes Villanova, PA 19085. Phone: 610-519-7275; Fax: 610-519-6319; including alteration in the structure and function of the E-mail: [email protected] brain (24-26). The impact of psychosocial stress during the developmental period marked by the maturation of neural Submitted: May 6, 2013; Revised: July 31, 2013; Accepted: October 2, 2013 networks may explain why schizophrenia typically presents Clinical Schizophrenia & Related Psychoses Summer 2016 • 101 Life Events, Class, and Schizophrenia Clinical Implications We believe this study provides substantial evidence for a temporal association between low-socioeconomic status (SES) of origin, stressful life events, and onset of positive symptoms of schizophrenia. We also believe that low SES of origin at least partly explains a biological vulnerability to stress which is activated during late adolescence, the developmental period of elevated risk for the emergence of schizophrenia. This is not a “formula” which applies to all people born into poverty, but only to that subset who were exposed to serious life stressors. In conclusion, there is a heightened likelihood of positive symptomatology among poor patients who experienced a stressful life event before symptoms onset. Our finding endorses the diathesis-stress theory, also known as the bio- psycho-social model (34). The stressful life event is considered to act as a trigger to a constitutional predisposition (dia- thesis) to schizophrenia. We hypothesize that a heightened reactivity to stressors is part of the core of the constitutional vulnerability of the diathesis-stress model. Consistent with other reports (40), we find that type of stressful event is not related to our central finding. The SES component of our finding connects with a number of possible risk factors, includ- ing diminished involvement of family members (84), fewer close and confiding relationships (6) and numerous stressful experiences in childhood and adulthood (58, 59). during late adolescence. One research team characterizes the symptoms (6, 45). Additionally, Tessner et al. (14) report phenomenon as a process which moves “from childhood de- that stressful life events during adolescence predict positive viance to frank psychosis” (7, p. 132). symptoms at onset. While some studies have established the general role of en- Other studies on life stressors and symptomatology have vironmental factors in the onset of psychosis (6, 7, 27), other produced mixed results. Although some report that higher research has concentrated on the type of stressful events that levels of stress are associated with worse symptoms (8), as- elevate risk. Aside from childhood trauma, other stressful sessments of symptom level in those studies are often ambig- events include combat in war (28-30), sexual and physical uous. The present study assesses severity according to types assault (31-33) and extreme interpersonal conflict (34). of symptoms: negative form and positive form. We employ An overwhelming majority of studies that examine the standardized measures of both groups of symptoms. Nega- connection between stressful life events and psychosis have tive symptomatology is a condition with poor prognosis and concentrated specifically on schizophrenia. The early study diminished responsiveness to medications (46-48). Some by Brown and Birley (35) confirmed the connection between contend that negative symptoms have such poor outcome life crises and onset of schizophrenia. For decades, that because they are linked with an abnormality in the physical study continued to be the primary source of evidence for the structure of the brain (49, 50). This may explain why onset of claimed connection. Many subsequent studies replicated illness is typically insidious for these patients (27). Positive the finding (8, 9, 36). On the other hand, a small number symptoms are a domain of psychopathology within schizo- of studies failed to establish the consistency and validity of phrenia theoretically associated with a different etiology the original finding of Brown and Birley (37-39). However, than negative symptoms. Indeed, since positive symptom- a huge cross-national meta-analysis sponsored by WHO im- atology is thought to be triggered by environmental stressors pressively concluded that socioenvironmental stressors of- (51, 52), the division of symptoms into negative and positive ten precipitate schizophrenic attacks (40). The role of stress- categories provides a useful analytic framework for assess- ful life events in the course of schizophrenia has many faces, ing the relative roles of diathesis and stress in the etiology of including relapse (41, 42, 11, 43), as well as onset of initial schizophrenia. Such is the case in the present study. symptomatology. No discussion of the role of stress on mental health would There are also some under researched variables that be complete without including socioeconomic status (SES) may connect with the influence of life stressors on onset of origin (53-56). Stress exposure and vulnerability to stress of schizophrenia. One is type of symptomatology. Read et play a central role in sociological studies of SES differentials al. (34) report that childhood abuse is a causal factor for in mental health. An impressive amount of research has schizophrenia in general and, more specifically, for positive demonstrated that low SES of origin is a risk for a wide range symptoms. Indeed, our own research in this area found that of mental disorders in adults (12, 57). Researchers in this type of childhood stressor incubates the specific symptoms area theorize that the interconnections among SES, stress of schizophrenia (44). Others report that daily stressors and and mental health result from low-SES individuals shoul- hassles later in life are independent predictors of positive dering a disproportionate number of stressful events in both 102 • Clinical Schizophrenia & Related Psychoses Summer 2016 Bernard J. Gallagher III et al. childhood and adulthood (58, 59). Upon admission, patients were evaluated by staff psy- Much of the research on SES and stress has concentrated chiatrists and other members of a multidisciplinary team on schizophrenia as the outcome variable (53). Those same within 48 hours for diagnosis and treatment plan purposes. studies report numerous stressful events experienced more Later diagnostic reviews were conducted for each patient ev- frequently by impoverished people, including extreme nega- ery three months or as needed during hospitalization. Since tive exposures to violence, death of a close relative and pa- some patients were discharged and readmitted over time, we
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