Distressful Life Events in Affective Disorder

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1 Journal of the Indian Academy of Applied Psychology July 2006, Vol. 32, No. 3, Distressful Life Events in Affective Disorder Anjali Kumari and Masroor Jahan Ranchi Institute of Neuro-Psychiatry and Allied Sciences, Ranchi The study was conducted to assess life events of the patients of bipolar affective disorder. Sample comprised of 60 subjects (20 manic patients, 20 depressive patients and 20 normal subjects). Diagnosis was done according to DCR of ICD-10. Assessment of severity of symptoms was done by Young Mania Rating Scale and Beck Depression Inventory for manic and depressive patients respectively. Normal subjects were screened by PGI-General Well Being Scale. Distressful Life Events Scale developed by Verma & Asthana, was administered to assess life events. Result shows that distressful life events were present in all three groups. However, life events of manic group were mainly related to social life, whereas, life events of depressed and normal subjects were mostly related to personal life. Key words: distressful life events, life events in mania, life events in depression. Life events stresses are concerned with situational encounters and the meaning that a person attaches to such events. It refers to our feeling, it is something of importance to us and is being jeopardized by events in our daily life. In other words, the stressful life events are causally linked to a variety of undesirable effects which influence our performance and health (Dohrenwend & Dohrenwend, 1974). An obvious requirement of any model of mental disorder, which can accommodate the influence of life events is that it emphasises agents either as formative or precipitating factor. Similarly, on the other hand, behavioural explanations are too general to be predictive for affective disorder. An adequate explanation of the influence of life events, therefore, must predict those conditions which produce psychological dysfunction and identify those persons who are at risk. Several models of psychiatric disorders exist which might explain the deleterious effect of life events. Other than genetic and biologic factors, which are known to play a major role in aetiology of mood disorder, psychosocial factors do influence onset timing, type, and outcome of affective episodes. But the nature of association and mechanism of action is still unclear (Johnson & Roberts, 1995). One proposed mechanism is social rhythm dysfunction (Ehlers et al., 1988). Stressor as a precipitant for relapse of bipolar affective disorder is applicable only for earlier episodes. This is a consistent research finding and has been explained by the sensitisation-kindling model (Post, 1992). The proposed time frame for life events preceding the onset of an episode for unipolar depression is four weeks (Bebbington & McCarthy, 1993). However, chronic difficulties up to six months have been shown to exert effects (Kendler et al., 1999). The time frame for life event stress precipitating relapse of bipolar affective

2 194 Distressful Life Events in Affective Disorder disorder has been proposed to be three weeks (McPherson et al., 1993). Recent life events of patients with completed suicide in bipolar / unipolar illness are found to be higher within the last three months (Insometsa et al., 1995). Some studies have identified the importance of exogenous factors (social and environmental factors) in precipitation of mania. Research findings suggest that 28 % of patients experienced distressful life events before a manic episodes, and manic patients had four times as many stressful life events in the 4 weeks preceding admission as compared to surgical control group (Ambelas, 1979), and 60% of the manic patients experienced stressful life events of various kinds, compared to only 13 % of the controls (Singh et al., 1984). On the contrary, Sclare and Creed (1990) did not find any relationship between life events and the onset of mania. Life events score in psychiatric patients who were more severely depressed had been found significantly greater during the six months preceding the onset of depression (Satija et al., 1982). Paykel and Cooper (1992) reviewed several studies which were conducted in many countries to assess the association between life events and depression, these studies had used control groups such as general population, medical patients, and other psychiatric patients). Findings of these studies suggest that stressful life events were more commonly present before onset of depression. Further social support predicts the course of bipolar disorder, and had a particularly strong effects on depressive symptoms (Persaud, 2000). Life events independent of affective illness and having significant negative impact were significantly more common (Kennedy et al., 1983). In life events, role of loss is more prominently reported in the literature. Loss includes interpersonal separation and deaths, loss of self esteem and other kinds of loss. Recent separation is commonly associated with onset of depression (Paykel & Cooper, 1992). Loss, threat and bereavement have been reported in manic patients (Ambelas, 1979). Death of close relatives, financial difficulties, death of spouse, and disappointment due to defeat in election turned out to be major life events contributing to manic pathology (Singh et al., 1984). Review of literature suggests that there are no consistent findings regarding the association of life event and affective disorder. There are only few studies have been conducted in India. Identification of life event in patients with bipolar affective disorder will be helpful in early identification of relapse, and also in relapse prevention. Hence present study was planned to find out nature of life events in patients with bipolar affective disorder. Method Sample Based on purposive sampling technique, a sample consisting of 60 subjects (20 manic, 20 depressive and 20 normal subjects) was drawn Patients were selected from Out-Patient Department of Ranchi Institute of Neuro- Psychiatry and Allied Sciences. Normal subjects were taken from local community. Patients were diagnosed according to DCR of ICD-10. Literate patients who could comprehend test items were included with informed consent. Whereas patients with severe level of psychopathology, co-morbid psychiatric disorder, mental retardation and substance abuse were excluded. Apart from exclusion criteria used for patients, in normal group only those persons were taken who do not have any history of mental disorder. To ensure the exclusion of probable psychiatric cases in normal group, only those subjects were chosen who scored below cut-off point

3 Anjali Kumari and Masroor Jahan 195 on PGI-general well being measure. The total number of 96 patients (Bipolar Affective Disorder) were interviewed, out of which 20 manic patients and 20 depressed patients fulfilled inclusion and exclusion criteria and gave informed consent to participate in the study. Mean age of manic group was 29.1 years (SD 6.934), of depressed group was 29.5 years (SD 5.229), and of normal group was years (SD 7.732).The soiodemographic characteristics of the sample are given in Table1. Table 1: Sociodemographic characteristics of manic, depression and normal subjects. Parameter Manic Depression Normal Chi-square N ( % ) N (% ) N (% ) Sex Male (%) 19 (95) 12 ( 60 ) 16 ( 80) * Female (%) 1 (5) 8 ( 40 ) 4 ( 20 ) (df=2) Education 1-7 th Class 4 ( 20 ) 5 (25 ) 1 ( 5 ) 8-12 th Class 11( 55) 8 (40 ) 3 (15) ** Graduate & Above 5 (25 ) 7 (35 ) 16( 80 ) (df=4) Marital Status Married 13 (65) 15 (75) 14 ( 70) Unmarred 7 (35 ) 5 ( 25 ) 6 (30 ) at df=2 Income Rs (65) 8 ( 40 ) 1 ( 5 ) Rs (30 ) 9 ( 45 ) 3 ( 15) ** Rs 10000) 1 ( 5 ) 3 ( 15 ) 16 ( 80) (df=4) Living Condition Rural 12 (60 ) 5 ( 25 ) 4 ( 20 ) Urban 6 (30 ) 13 ( 65 ) 16 ( 80) * Semi-urban 2 (10 ) 2 ( 10 ) - (df=4) Religion Hindu 15 (75 ) 17 (85 ) 17 ( 85) Muslim 5 (25 ) 3 ( 15 ) 2 ( 10 ) 6.83 Christian ( 5 ) (df=4) Occupation Employed 10 (50 ) 6 (30 ) 15(75 ) * Unemployed 10 (50 ) 14 ( 70 ) 5 ( 25 ) (df=2) *= p<.05; ** = p <.01

4 196 Distressful Life Events in Affective Disorder Tools Rating of manic and depressive symptoms was done using Young Mania Rating Scale and Beck Depression Inventory respectively. Normal subject were screened for probable psychiatric disorder by PGI General Well Being Scale. Distressful life events were recorded using Distressful Life Events Scale. Young Mania Rating Scale (YMRS): The YMRS is a 11 items scale developed by Young s et al. (1978). It was designed to be administered by a trained clinician in a minute interview. The severity rating for each of the 11 items is based of the patient s subjective report of his or her condition over the previous 48 hours and on the clinician s behavioural observations during the interview with emphasis on the clinician s observations. The Beck Depression Inventory (BDI): It is a 21 items scale developed by Beck et al. (1961). Each category describes specific behavioural manifestation of depression and consists of a graded series of four to five selfevaluative statements. Numerical values from 0-3 are assigned to each statement to indicate the degree of severity. PGI General Well Being Scale: It was developed by Verma and Verma (1989).. The reliability of the scale is.98 and validity is.49. Distressful Life Events Scale: It was developed by Verma and Asthana. in order to quantify the total stress experienced by different clinical groups. The scale consists of unpleasant and undesirable life events and the subject is asked to mark the events, which he / she felt in his / her life and is effected by them. Rating is done on 3 point scale. Split half reliability of the scale ranges from.90 to.94. Test-retest reliability ranges from.80 to.84. Validity ranges from.78 to.80. Procedure Socio-demographic and clinical data sheet was filled after interview of subjects and reliable informants. After initial screening and information collection, Distressful Life Events Scale was administered to all subjects according to the standard procedure given in the manual. Results Ten most commonly present life events of manic, depressed and normal subjects are given in Tables 2, 3, and 4 respectively. Result shows that distressful life events of manic group were mainly related to social life (e.g., afraid of defamation, loss of social prestige etc.), whereas distressful life events of depressed and normal group were more related to personal life (e.g., death of loved one etc.). Illegal pregnancy, demotion, distorted relation to son/daughter, unpleasant changes in business, son/daughter go away home, involved in crime corruption and other complaints, and unemployment of son was not present in any groups. Group comparison was done by using chi-square test with Yate s correction. Death of loved one was present in 55% normal subject followed by depression (30%) and mania (15%). This difference was statistically significant suggesting that death of loved one was present significantly more in the life of normal group. Marital tension or unsatisfaction was found in 30% manic and depressed subjects and 5% normal subject. This difference was statistically significant indicating that manic and depressed group were having more marital tension or unsatisfaction. Service termination / loss in business was found only in 30% manic subjects and 5% normal subjects. It was absent in depressed group. Statistically significant difference in occurrence of life events in the three groups suggested that service termination / loss in business was more in manic group. Change in social work activity was present in 20% normal subjects, 10% depressed subjects and 5% manic subjects. There was significant difference indicating that normal subjects had more change in social work activity.

5 Anjali Kumari and Masroor Jahan 197 Table 2: Ten most commonly present life events in manic patients. S.No. Description Presence of life events N % 1 Problem in sleep Marital tension* Service terminated/ loss in business Afraid of defamation Addict of drug/ alcohol Loss of social prestige Not getting desired service/ business Loss of property Punished by Government Sexual problem* 3 15 * Applicable only for married subjects Table 3: Ten most commonly present life events in depressed patients. S.No. Description Presence of life events N % 1 Problem in sleep Not getting desired service/ business Death of loved one Marital tension* Addict of drug/ alcohol Physically handicap/ looking ugly Unmarried ** Death of spouse* Severe trauma/ accident and illness Persistent tension to sibling 4 20 * Applicable only for married subjects ** Applicable only for unmarried subjects

6 198 Distressful Life Events in Affective Disorder Table 4: Ten most commonly present life events in normal controls. S.No. Description Presence of life events N % 1 Death of loved one Not getting desired service/ business Severe health problem of family member Change in social activity Involve in litigation Not getting appropriate promotion Addict of drug/ alcohol Increased work pressure Not getting marriage of daughter/ sister Change in responsibility 3 15 Discussion Study was conducted to assess and compare distressful life events and life satisfaction of manic and depressed patients, and normal subjects. Fifty distressful life events for male and 54 for female subjects were assessed. In patient groups (both mania and depression) problem in sleep was most often reported (75% and 80%, respectively). This may be because of illness as sleep problem is a clinical feature of manic and depressed patients. Marital tension, addiction to drugs and alcohol and not getting desired service / business were distressful life events that were present in both patient groups, however, not getting desired service / business and addict of drug and alcohol were reported by normal subjects also as a part of top ten distressful life events. Marital tension was more prominently present in manic and depressed patients. In earlier studies also marital tension has been reported as stressful life event of depressed patients (Paul, 2000; Wade & Kendler, 2000). Other life events that emerged in top 10 for manic patients were mainly social in nature, like, afraid of defame, loss of social prestige, service termination and loss in property etc. Kumar and Ram (2001) and Singh et al. (1984), have also reported financial loss in manic patients. Life events related to social life of manic patients is accordance to the hypothesis of social rhythm dysfunction in manic patients. Malkoff-Schwartz et al. (1998) have also reported that the frequency of life events disrupting social rhythm is significantly present in manic patients. In depressed group life events in top ten were death of loved one, looking ugly, unmarried, death of spouse etc. These life events are mainly personal in nature. However, death of loved one was reported by most of the normal subjects also. These findings are consistent with the report of earlier studies suggesting that exogenous factors are more related to manic episode, whereas, life events related to personal life are more common in depressed patients. Death of spouse as a distressful life event of depressed patients is earlier reported by

7 Anjali Kumari and Masroor Jahan 199 Carnelley et al., (1999) and Chong et al., (2001). Other life events were either absent or were very less frequently reported by all three groups. According to bio-psycho-social approach, psycho-social stressors may precipitate an episode of affective disorder or it may be associated with increased severity of illness. However, presence of few similar life events in all three groups or non-significant group difference, as found in present study, suggests that stressful life events are part of normally functioning persons also. Hence, mere presence of life events may not be considered responsible for emergence or relapse of affective disorder. It may be because of the difference in perception of and coping with the distressful life events. The cognitive-behavioural model of bipolar affective disorder also emphasises on cognitive styles of these patients. A body of research focused on cognitive factors such as attribution style (Alloy et al., 1999), perfectionism, deficits in problem solving skills, and also maladaptive schemata. These factors appear to play a significant role in the interaction of severe changes in behaviour, reactions to and the creation of significant psychosocial stressors, disruptions in chronobiological functioning and varied responsiveness to psychotropic medications. Hence, significant variables affecting the perception of life events and ways of coping with it should be explored in detail in further studies. References Alloy, L., Reilly-Harrington, N. A., Fresco, D. M., Whitehouse, W. G., & Zechmeister, J. S. (1999). Cognitive styles and life-events in subsyndromal unipolar and bipolar disorders: Stability and prospective prediction of depressive and hypo manic mood swings. Journal of Cognitive Psychotherapy, 13, Ambelas, A. (1979). Life events and mania : A special relationship. British Journal of Psychiatry, 150, Beck, A. T., Waed, C. H., and Memdelson, M., (1961) An inventory for measuring depression. Archives of General Psychiatry, 4, Bebbingtoin, P. G., & McCarthy, B. (1993). Stress incubation and the onset of affective disorder. British Journal of Psychiatry, 162, Carnelley, K. B.; Wortman, C. B., & Kessler, R. C. (1999). The impact of widow- hood on depression: findings from a prospective survey. Psychological Medicine, 29 : Chong, M.; Chen, Y.; Tsang, C. C.; Yeh, H. Y.; Chen, T. Y.; Lee, C. S,;. Tang, Y. H. T. C., & Lo, H. Y. (2001). Community study of depression in old age in Taiwan, Prevalence, life events and socio- demographic correlates. The British Journal of Psychiatry, 178 : Dohrenwend, B.S., & Dohrenwend, B.P. (1974). Overview and prospects for research on stressful life events. In: B.S. Dohrenwend,. and B.P.Dohrenwend, (Eds.) Stressful life events. Their nature and effects. New York: Wiley, pp Ehler, C. L.; Frank, E., & Kupfer, D. J. (1988). Social zeitgebers and biological rhythms: a unified approach to understanding the aetiology of depression. Archives of General Psychiatry, 45, Insometsa, E.; Heikkiner, M, Hennksson, M.; Aro, H., & Lonnqvist, J. (1995). Recent life events and completed suicide in bipolar affective disorder. A comparison with major depressive suicide. Journal of Affective Disorder, 33, Jhonson, S.I., & Roberts, J.E. (1995). Life events and bipolar disorder: Implications from biological theories. Psychological Bulletin, 117, Jhonson, S.I.,Sandow D., Meyer, B.; Winters, R.; Miller, I.; Solomon, D., & Keitner, G. (2000). Increases in Manic symptoms after life events

8 200 Distressful Life Events in Affective Disorder involving goal attainment. Journal of Abnormal Psychology, 109, Kendler, K. S.; Karkowski, L. M., & Prescott, C. A. (1999). Causal relationship between stressful life events and the onset of major depression. American Journal of Psychiatry, 156, Kennedy, S., Thompson, R., Stancer, H.C., Roy, A., & Persad, E. (1983). Life events precipitating mania. British Journal of Psychiatry, 142, Kumar, R., & Ram, D. (2001) Life events precipitate affective disorder. Indian Journal of Psychiatry, 26, Malkoff-Schwartz, S., Frank, E., & Andersen, B. (1998). Stressful life events and social rhythm disruption in the onset of manic and depressive bipolar episodes. Archives of General Psychiatry, 55, McPherson, H.; Herbison, P., & Ronan, S. (1993). Life events and relapse in established bipolar affective disorder. Brazilian Journal of Psychiatry, 163, Paul. (2000) Life events integers bipolar disorder. Indian Journal of Psychiatry, 2, Paykel, E. S., & Cooper, Z. (1992). Life events and social stress. In: E.S. Paykel (Ed.). Handbook of affective disorders, New York: The Guilford Press, pp Persaud, C. J. (2000). Social support predicts course of bipolar disorder. American Journal of Psychiatry, 152, Post, R.M. (1992). Transduction of psychosocial stress into the neurobiology of recurrent affective disorder, American Journal of Psychiatry, 149, Satija, I.; Kallu, J. K., & Pande, Y. S. (1982). A comparative study of life events in psychiatric patients with high and low depression. Paper presented at Annual Conference of Indian Psychiatric Society, Madras. In: C. f. D. M. Pestonjee (1992). Stress and coping: The Indian experience, New Delhi: Sage Publication. Sclare, P., & Creed, F. (1990). Life events and the onset of mania. British Journal of Psychiatry, 156, Singh, G., Kaur, D., & Kaur, H. (1984) Presumptive stressful life events scale- a new stressful life events scale for use in India. Indian Journal of Psychiatry, 26, Verma, S. K., & Verma, A. (1989). Manual for PGI General Well-being Measure. Ankur Psychological Agency: Lucknow Verma, K. B., & Asthana, M. (1990). Manual of Distressful Life Events Scale. Rupa Psychological Centre: Varanasi. Wade, I. & Kendler, H.J.(2000) Life events precipitate affective disorder. Indian Journal of Abnormal Psychology, 3, Young, R. C., Biggs, J.T., Ziegler, V.E., & Meyer, D.A. (1978). A rating scale for mania reliability, validity and sensitivity. British Journal of Psychiatry, 133, Received: December 23, 2005 Accepted: June 03, 2006 Anjali Kumari, M.Phil M&SP, Research Scholar, Department of Clinical Psychology, Ranchi Institute of Neuro-Psychiatry & Allied Sciences, Kanke, Ranchi-6 Masroor Jahan, PhD, Clinical Psychology, M.Phil M&SP, presently Asst. Professor of Clinical Psychology, RINPAS, Ranchi. masroorjahan@yahoo.com Note: This paper is based on the M.Phil dissertation of the first author

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