Bruce P. Dohrenwend

Inventorying Stressful Life Events as Risk Factors for Psychopathology: Toward Resolution of the Problem of Intracategory Variability.

An explosion of research on life events has occurred since the publication of the Holmes and Rahe checklist in 1967. Despite criticism, especially of their use in research on psychopathology, such economical inventories have remained dominant. Most of the problems of reliability and validity with traditional inventories can be traced to the intracategory variability of actual events reported in their broad checklist categories. The purposes of this review are, first, to examine how this problem has been addressed within the tradition of economical checklist approaches; second, to determine how it has been dealt with by far less widely used and far less economical labor-intensive interview and narrative-rating approaches; and, third, to assess the prospects for relatively economical, as well as reliable and valid, solutions.

The Role of Adversity and Stress in Psychopathology: Some Evidence and Its Implications for Theory and Research

Three lines of research--studies of extreme situations, epidemiological investigations of relations between socioeconomic status (SES) and psychiatric disorders, and a quasi-experimental test of the social causation-social selection issue raised by the epidemiological findings--provide strong evidence that environmental adversity is important in the occurrence not only of post-traumatic stress disorder (PTSD) but also of other types of psychopathology, including major depression, alcoholism, substance use disorders, antisocial personality disorder, and nonspecific distress. Leads from this triad of studies are developed into a basic proposition about the nature of the role of adversity and stress. The core of this proposition is that the likelihood of onset of the above types of disorder increases with two factors: (1) the proportion of the individuals usual activities in which uncontrollable negative changes take place following a major negative event; and (2) how central the uncontrollable changes are to the individuals important goals and values. The role of environmental adversity in bringing about these uncontrollable changes varies with gender, ethnic/racial status, and SES in our own and other modern, urban societies. The types of psychopathology that develop and their course vary with both the types of adversity (e.g., whether life threat is involved) and with the personal predispositions of the individuals who experience the adversity and stress (e.g., family history of particular types of psychopathology).

Some Issues in Research on Stressful Life Events

This paper is concerned with the kind of work that is needed in order to provide a more solid scientific foundation for the belief that life stress causes illness. Although indirect evidence from controlled laboratory studies and from extreme situations provides strong indications of the general relationship between stress and illness, the evidence concerning the effects of naturally occurring and more ordinary stressful life events is less clear. Although we have a body of research indicating that life events are associated with a wide range of disorders and distress, it does not provide a clear picture of the nature and strength of this relationship. In order to clarify our understanding of how stressful life events affect health and illness, we will need to deal with methodological issues that have emerged from research to date and to tackle a major substantive problem that has been largely neglected. The methodological issues are three: a) definition of the populations of life events to be studied; b) measurement of the magnitudes of the life events; and c) use of a research design appropriate to the question to be answered. The substantive issue concerns factors that mediate the impact of life events. Each of these issues is examined in turn in this paper.

A Longitudinal Investigation of Social Causation and Social Selection Processes Involved in the Association Between Socioeconomic Status and Psychiatric Disorders

Social causation theory and social selection theory have been put forth to explain the finding that low socioeconomic status (SES) is associated with risk for psychiatric disorders. The predictions of both theories were investigated using data from a community-based longitudinal study. Psychosocial interviews were administered to 736 families from 2 counties in New York State in 1975, 1983, 1985-1986, and 1991-1993. Results indicated that (a) low family SES was associated with risk for offspring anxiety, depressive, disruptive, and personality disorders after offspring IQ and parental psychopathology were controlled, and (b) offspring disruptive and substance use disorders were associated with risk for poor educational attainment after offspring IQ and parental psychopathology were controlled. These findings indicate that social causation and social selection processes vary in importance among different categories of psychiatric disorders.

Socioeconomic Status and Depression: The Role of Occupations Involving Direction, Control, and Planning

This article proposes a social causation explanation for the association between SES and depression/distress. The model links SES, occupational direction, control, and planning (DCP), personality factors, and depression/distress in a causal sequence. The data to test the social causation model against alternative, social selection models are derived from samples of psychiatric patients and community residents in Washington Heights, New York City. The key factor of DCP is operationalized using ratings from the Dictionary of Occupational Titles. The results support the social causation model and cannot be accounted for by several tests derived from social selection models. Thus the results increase the plausibility of the social causation model and suggest the need for further research on the links between occupational conditions and mental disorder.

Measuring small life events

The development of an inventory to assess small events is described. In the construction of the inventory specific criteria were established and existing event inventories were screened for items and new items written to fit these criteria. The event had to denote an observable change in a persons everyday life, have a discrete beginning, be classifiable as either desirable or undesirable, and be scaled as having an average of 250 Life Change Units or less using B. S. Dohrenwend, Krasnoff, Askenasy, Dohrenwends (1978) magnitude estimation parameters. The inventory was constructed to cover events in major areas of life concern: family, work, leisure, household, financial, health/illness, nonfamily relations, crime/criminal activity, education, religion, and transportation. Two studies are reported that test the utility of the inventory.

SOCIAL STATUS AND PSYCHOLOGICAL DISORDER: AN ISSUE OF SUBSTANCE AND AN ISSUE OF METHOD *

The most consistent demographic finding reported in social psychiatric field studies is an inverse relation between social class and psychological disorder. This relationship has been interpreted on the one hand as evidence of social causation, with low status producing disorder, and on the other as evidence of social selection, with pre-existing disorder determining social status. This substantive issue could turn on a simple question of fact: whether Negroes and Puerto Ricans in New York City have higher or lower rates of disorder than their class counterparts in more advantaged ethnic groups. The facts, however, are not available from existing research. The results of field studies contain clues to group differences in modes of expressing distress, including some that involve problems of response bias, but the evidence is far from clear about the relation of the symptoms reported to the underlying psychiatric condition of individuals. It would seem that the substantive issue of social causation vs. social selection must yield precedence to resolution of the central unsolved problem of psychiatric epidemiology-the measurement of untreated psychological disorder. EPIDEMIOLOGICAL studies have been held to support a variety of hypotheses about the social causation of psychological disorder. Most often, the causal role of social factors is inferred from rate differentials according to geographical location or social category. These correlations have been viewed as pointing to the etiological significance of such factors as social disorganization, social isolation, migration, accul

Self-reported Attenuated Psychotic Symptoms as Forerunners of Severe Mental Disorders Later in Life

CONTEXT It has been suggested that attenuated psychotic symptoms (APSs) reported by people who do not have psychotic disorders signal risk for later severe mental illness. OBJECTIVE To investigate this suggestion using follow-up assessments of hospitalization for clinical diagnoses of nonaffective psychotic and other psychiatric disorders. DESIGN Longitudinal cohort study of self-reported APSs with outcome assessment of severe mental illness obtained through linkage with a national hospitalization case registry. SETTING Israel. PARTICIPANTS A stratified full probability sample of 4914 persons aged 25 to 34 years who were screened for psychopathology in the 1980s. MAIN OUTCOME MEASURE Subsequent psychiatric hospitalization was ascertained using the psychiatric hospitalization registry, with a mean follow-up of 24 years. RESULTS After removing subjects with diagnosable psychotic disorders at baseline, 57.2% of the remaining sample reported at least 1 weak (infrequent) APS and 14.3% reported at least 1 strong (frequent) APS in the year preceding the assessment. Self-reported APSs predicted risk of later hospitalization for nonaffective psychotic disorders, mostly during the 5 years after baseline (adjusted odds ratio = 4.31; 95% CI, 2.21-8.41; positive predictive value = 1.27%; population attributable risk fraction = 33%). Also, APSs increased the risk of later hospitalization for other psychiatric disorders, albeit to a lesser extent (adjusted odds ratio = 2.21; 95% CI, 1.02-4.82). CONCLUSIONS Self-reported APSs signal risk for later nonaffective psychotic disorders but are not clinically useful as predictors. The difference between these population-based data and the high-risk literature in terms of the positive predictive value (1% vs 10%, respectively) and the time window of transition (5 years vs 12 months, respectively) can be attributed to the selective enrichment strategies that produce high-risk samples.

Estimating the Prevalence of Childhood Psychopathology: A Critical Review

Abstract Special methodological problems in the epidemiology of childhood psychopathology are addressed in this paper. Despite the methodological problems, we have attempted to provide as accurate an estimate as possible of the prevalence of childhood psychiatric disorder in the United States. Based on the national prevalence studies to date, we conclude that the overall rate of clinical maladjustment in the United States is probably no lower than 11.8%, specific rates varying across age, social class, ethnic group, and geographic region.

Problems of recall and misclassification with checklist methods of measuring stressful life events.

The prevalent use of life event category checklists to facilitate event recall may be one reason that previous studies find that life events play only a small and ambiguous role in the development of health problems. In this study, 136 persons with temporomandibular pain disorder syndrome (TMPDS) and 131 healthy controls reported the occurrence of life events in 10 monthly interviews, using an event category checklist. At the end of the study, they reported retrospectively and in detail about life events over the previous monthly periods. Only one quarter of the event categories appeared in both the monthly interviews and retrospective report for the same period. Detailed analyses revealed problems of inaccuracy inherent in checklists that exacerbate problems of recall. The findings indicate that checklist category approaches should not be used when the goal is to understand the role of stress in adverse health outcomes. Suggestions are made about more adequate methods.