Soc Psychiatry Psychiatr Epidemiol (1991)26:212-216 9 Springer-Verlag 1991

Social Psychiatryan~

PsychiatricEpidemiology

Subjective stress in schizophrenic patients*

R. M. G. Norman and A. K. Malla

Department of Psychiatry,University of Western Ontario and Victoria Hospital, London, Ontario, Canada Accepted: June 26, 1991

Summary. The relationship of major life events and daily stressors to subjective stress was investigated in outpatients suffering from schizophrenia. Daily stressors or hassles were found to be more predictive of subjective stress than were major life events. These findings were not influenced by whether a cross sectional or prospective analysis was used. The implications for future research on stress and schizophrenia are discussed.

One of the many controversies surrounding the disorder of schizophrenia concerns the extent to which it is influenced by psychosocial stressors. Clinicians who treat schizophrenic patients often assume that stress does play a significant role in the development and course of symptoms in those individuals who are vulnerable to the disease. There has also been considerable speculation concerning reasons why individuals susceptible to schizophrenia may be especially sensitive to the effects of stress (e.g. Spring and Coons 1982; Nuechterlein and Dawson 1984; Nicholson and Neufeld 1989). In contrast to the popularity of such assumptions concerning the role of stress, reviews of the research literature on the relationship between psychosocial stress and symptomatology in schizophrenia have generally concluded that the evidence for such a relationship is very weak (Rabkin 1980; Tennant 1985). Past research on stress and schizophrenia has relied almost exclusively on measures of major life events as an index of stress (e. g. Brown and BMey 1968; Chung et al. 1986; Hardesty et al. 1985). This is particularly noteworthy in the light of two observations. This first is the repeated finding in research on other disorders and symptoms that everyday and comparatively minor stressors or hassles are more important predictors of experienced stress and symptomatology than are measures of major life events (Kanner et al. 1981; Monroe 1983; Zarski 1984). The second is the * This research was supported by a grant from the Upjohn London Neurosciences Program. Assistance was also provided by North Bay PsychiatricHospital and Dr. Peter Williamsonand the staff of the active treatment unit of London Psychiatric Hospital.

suggestion from scholars interested in both psychosocial and biological aspects of schizophrenia, that individuals who suffer from this disorder may be particularly likely to be stressed in response to minor demands for adaptation more often than in response to unusual and major life changes and challenges (Beck and Worthen 1972; Donovan, Dressler and Geller 1975; Weinberger 1990). The only published study to examine the possible effect of both major and minor life events on schizophrenia is reported in a recent paper by Malla et al. (1990). In that study case records of a one year period were examined for 21 schizophrenics who were being followed as outpatients. Information was abstracted from the records in order to assess the levels of major and infrequent life events such as marriages, separations, loss of job, promotions, deaths of significant others, etc. and also more regular day to day challenges and changes in spheres of life such as work, school, interpersonal relations, etc. The data suggested that both types of events were related to worsening clinical state. Malla et al., concluded that their results "provide some preliminary evidence for the importance of both major and minor life events in relation to relapse in schizophrenia. We suggest, therefore, that research should address life events of all magnitudes to ascertain their true role in schizophrenia." Unfortunately, because of the nature of their study, Malla et al. could not provide data based on standardized measures. What is the relative importance of major versus comparatively minor daily stressors as predictors of subjective stress in patients suffering from schizophrenia? In this paper we present the first published data relevant to this question using standardized measures.

Method

Subjects
Subjects were recruited from those attending outpatient clinics at Victoria Hospital or London Pschiatric Hospital in London Ontario or North Bay Psychiatric Hospital in

213 North Bay, Ontario. All patients were interviewed by one of two experienced psychiatrists using the Structured Clinical Interview for D. S. M. III-R (Spitzer et al. 1985) to confirm the diagnosis of schizophrenia. Criteria for inclusion in the sample were: having a diagnosis of schizophrenia; being between the ages of 17 and 60; having had at least one previous admission to hospital for treatment of schizophrenia; and having been stabilized on medication as outpatients for at least three months prior to entry into the study. Exclusion criteria were: having organic brain disease or a history of head injury; significant drug or alcohol dependence; and/or a history of affective disorder. One hundred patients who met these criteria were approached to participate in the study. Of these 100 patients, it was possible to obtain consent and the necessary information from 95. signed to measure stressors in the form of common everyday difficulties and challenges. It includes items assessing the reported pressures, problems or difficulties associated with such circumstances as "not enough money for clothing", "family responsibilities", "transportation problems", etc. The are a total of 118 items in this scale. Respondents are asked to indicate which of the items has occurred to them over the previous month, and for those that had occurred they are asked to rate on a three point scale the severity of the hassle. Kanner et al. (1981) have found this scale to have adequate levels of test-retest reliability, and, as previously noted, a number of investigators have found the Hassles Scale to be more predictive of later psychological and physical symptoms than measures of major life events using samples from several populations other than patients suffering from schizophrenia (Kanner et al. 1981; Monroe 1983; Zarski 1984). Both the PERI Scale and the Hassles Scale have in past research been scored in two ways. One method of scoring is simply to count the number of items endorsed by the respondent - i. e., how many major life events or how many hassles does the subject report having experienced. In the second method of scoring each item is weighted by an index of the stress associated with it. In the case of the PERI Scale this weighting is based on estimates carefully elicited during the scale construction from independent judges of the amount of personal readjustment that would typically be required in response to the event (Dohrenwend et al. 1978). In the case of the Hassles Scale the weighting is based on the respondents own ratings of the severity of the hassles endorsed. The procedure used in the Hassles Scale has been particularly contentious because of the probable confounding of external stressors with the subjective stress response (cf. Dohrenwend and Shrout 1985; Lazarus et al. 1985). Reich et al. (1988) have presented evidence to support the use of the simple number of items endorsed on the Hassles Scale as a measure of external minor stressors independent of subjective reaction. For this reason, and because simple number count on the PERI has been used successfully in past research on life events and symptomatology in schizophrenia, it was initially decided to use number of items endorsed as the primary index of both major life events and daily hassles. The third measure was the Perceived Stress Scale (Cohen et al. 1983). This 14-item scale was developed in order to provide a psychometrically sound global measure of perceived stress. It is designed to measure the extent to which respondents find their lives stressful (i. e. subjectively overloading, unpredictable, and uncontrollable). Typical items ask respondents to indicate on a five point scale how often during the past month they have "been upset because of something that happened unexpectedly?" or "found that you could not cope with all the things that you had to do?". One of the primary reasons for the development of the PSS was to provide an index of general experienced level of stress that could be used as an outcome measure for assessing the effects of various types of stressful events. The PSS has shown adequate levels of internal reliability. The PSS has been found to have construct validity as a measure of stress which is related to various indicators of life events, psychological distress,

Procedure

After providing a general introduction 1:o the project and obtaining consent, a number of assessments were carried out with reference to the patients. Demographic information such as age, gender, marital status, ,educational background and employment were recorded on the basis of chart information and interviews with patients. Total number of admissions for psychiatric treatment and current neuroleptic medication were recorded from patient charts and confirmed with clinicians. Patients were asked to complete three self-report instruments of relevance to the assessment of stress. These were the Psychiatric Epidemiology Research Interview (PERI) Life Events Scale (Dohrenwend et al. 1978); the Hassles Scale (Kanner et al. 1981); and the Perceived Stress Scale (Cohen et al. 1983). The PERI Life Events Scale includes 102 items concerning major changes in one's life situation such as getting married, being fired, changing residences, legal difficulties, illnesses, etc. The items cover many areas of a person's life including school, work, love and marriage, family, residence, crime and legal matters, finances, social activities, health, etc. Respondents are simply asked to indicate whether each of the events listed had occurred to them for the time period under consideration. In the development of this instrument Dohrenwend et al. (1978) took particular care in the selection of items and procedures for judging the personal readjustment likely to be associated with each item. The PERI Scale formed the basis for the measure of life event stressors used by Ventura et al. (1989) in their sophisticated longitudinal study of the relationship between stressful life events and increases in symptomatology of schizophrenia. Questions concerning life events were asked with reference to the one month prior to the interview date. This time period was selected because past studies have shown that it is the occurrence of major life events within the immediately preceding three to four weeks that appear most likely to have an impact on symptoms state of schizophrenic patients (Brown and Birley 1968; Day et al. 1987; Ventura et al. 1989). Minor or daily stressors were assessed using the Hassles Scale (Kanner et al. 1981). This instrument was de-

214 Table 1. Means and standard deviations of measures Measure PERI Scale Hassles Scale Perceived Stress Scale (PSS) Mean 1.0 43.2 22.6 s.d. 1.2 43.0 8.4 As can be seen in the top of Table 2, scores on the Hassles Scale were significantly correlated with perceived stress, but P E R I Scores were not. As would be expected from these results, when both the Hassles and P E R I Scales were included in a multiple regression equation to predict perceived stress, only the Hassles Scale was found to have a significant regression weight. These findings are consistent with the hypothesis that minor stressors and hassles are a more important source of variation in subj ective stress than are life events. It should be noted that similar results are obtained when we use the total P E R I scores based on a weighting of the events reported by the judged level of readjustment required in order to adapt to them. These weightings were based on those provided by D o h r e n w e n d et al. (1978). As can be seen in Table 2, such a weighted score on the P E R I did not show a significant correlation with the PSS. When scores on the Hassles Scale were calculated to include a weighting based on the severity rating provided by the respondent for each item, there was a slight and non-significant increase in the magnitude of the correlation to 0.46 (P < 0.001) from the 0.38 found when using the simple n u m b e r of Hassles that were endorsed. Reich et al. (1988) have presented evidence that scores on the Hassles Scale can be divided into two components. The total n u m b e r of hassles endorsed as having occurred appears to reflect primarily external sources of stress, whereas the average rating of severity of hassles that are reported reflect more the contribution of the characteristics of the respondent to subjective stress. Consistent with their proposal, we found that scores based on n u m b e r of items endorsed and the average severity rating to be uncorrelated (r=0.10, n.s.) suggesting that these are independent components. We might expect, as Reich et al. have found, that each of these components has an independent influence on perceived stress. We have already reported the correlation between the n u m b e r of Hassles endorsed and the PSS to be 0.38. The correlation between the average severity index of the Hassles Scale and the PSS based on the entire sample was 0.24 (P < 0.01). When both were entered into a multiple regression to predict scores on PSS, they each made a significant contribution to the prediction (multiple r = 0.48). A stepwise regression showed that the n u m b e r of hassles (reflecting external stressors) predicted the greatest amount of variance in subjective stress. A major challenge in the investigation of stress in patients suffering from schizophrenia is the possibility that some stressors may be occurring as the result of patients' symptomatology. This is, of course, a particularly important issue for researchers who are interested in the influence of stress on symptoms. It has become customary to refer to those stressors which are unlikely to be influenced by symptoms as independent stressors. We examined whether stressors which differed in likely level of symptom independence also differed in the magnitude of their relationship to subjective stress. In order to do this we had five psychiatrists experienced in the treatment of patients with schizophrenia judge each item on both the P E R I and the Hassles Scales for the extent to which it was likely to be a result of symptoms of the disorder. These ratings were

Table 2. Correlations of PERI and Hassles Scales with Perceived Stress Scale

Measure A. PERI Scale (unweighted) B. Hassles Scale (unweighted) C. PERI Scale (weighted) D. Hassles Scale (weighted) E. Average Severity of Hassles Each scale divided by rated level of symptom independence of items: E High Ind. PER1 items G. Low Ind. PERI items H. High Ind. Hassles items I. Low Ind. Hassles items * P<0.01; ** P<0.001

Correlation with PSS 0.15 0.38** 0.14 0.46** 0.24*

0.07 0.24* 0.42** 0.32**

physical symptomatology, use of health services and health related behaviour (Cohen and Williamson 1988; Cohen et al. 1983; Cohen and Lichtenstein 1990; Glasgow et al. 1985). Cohen et al. (1983) have found the PSS to be a better predictor of a range of outcomes than measures based on external events. It appears, therefore, to be a valid measure of subjective stress that mediates the effect of external events on individuals' well being.

Results

Characteristics of the sample

Approximately two thirds of the sample were males. The average age for males who participated in the study was 32.9 years and for females it was 36.7. Approximately half of the sample had some form of employment, but only just under one quarter held full time jobs. The average number of hospitalizations for psychiatric treatment had been 3.3 with a range of one to 13. All patients were receiving neuroleptics. The average daily C P Z equivalence dosage was 484.13 with a standard deviation of 475.74. Further details concerning the sample are available in N o r m a n and Malla (in press).

Live events, hassles and perceived stress

The mean scores and standard deviations of each of the scales used are presented in Table 1. There were no significant differences between genders on any of these scores.

215 carried out using five point scales. There was an average correlation of 0.72 between these judgements across psychiatrists. The mean of the ratings for each item was used as the index of the likely degree of symptom independence of the stressor. On each scale a median split of items was carried out on the basis of their rated level of symptom independence. The total score on each split half of both the P E R I and Hassles Scales was then correlated with the PSS. Results are presented in the lower part of Table 2. There was no significant difference in the correlation of high and low independent Hassles items with subjective stress (r = 0.42 and 0.32 respectively, P < 0.001 for both). For the P E R I Scale, however, when using those items judged relatively low on symptom-independence there was a significant correlation (r = 0.24, P < 0.01), but not when using items high in independence (r = 0.07, n. s,). It might be argued that the one month period with reference to which major life events has been assessed was too brief a time to detect major events that might be influencing subjective stress. As noted earlier, the one month period was selected because of past findings that it appears to be life events for an antecedent period of three to four weeks that are most likely to have an effect on the clinical state of patients with schizophrenia. Nevertheless, to check on the possibility that we might be missing the effects of more distal events on perceived stress additional data was subsequently collected on 50 individuals from the original sample. One of the purposes of this additional data collection was to examine the effects of major life events over a six month period on perceived stress. Although researchers in the past have assessed life events with reference to periods of time much longer than one month, there is evidence that the reliability of recall of events for such long time periods is unsatisfactory (Neugebauer 1983; Klein and Rubovits 1987). For this reason, rather than simply asking for one retrospective report of life events concerning a longer period of time, we carried out assessments on a monthly basis for six months using the PERI Scale, the Hassles Scale and the PSS. We then calculated the average for each of the six months on both the P E R I and the Hassles Scale to predict perceived stress at the time of the final assessment. The results using this additional data were similar to those based on data for a one month period. For instance, the correlation between the unweighted PERI Scale and the PSS was 0.02 (n. s.) and for the Hassles Scale it was 0.47 (P<0.001). In a multiple regression on this six month data only the Hassles scale was found to carry a significant weight in the prediction of perceived stress. ing from cognitive impairments. Spring and Coons in 1982 suggested that empirical support be sought for the clinical observation that patients with schizophrenia are often strongly effected by subjectively traumatic, but objectively trivial events. The work o fMalla et al. (1990) and the results of this paper suggest that comparatively minor daily stressors do indeed have a significant effect on such patients. The current study shows that the relationship between daily hassles and subjective stress is greater than that between major life events and subjective stress. Our findings support the common clinical impression that patients with schizophrenia can perceive threat in challenges or changes that might be seen by others as comparatively minor. The results are also consistent with evidence that the emotional tone of a patient's immediate environment may be an important predictor of likelihood of relapse. For instance, it appears likely that family characteristics such as "expressed emotion" or ~'communication deviance" which are commonly implicated in likelihood of relapse (Brown et al. 1972; Miklowitz et al. 1986; Vaughn et al. 1984) are more likely to be reflected in measures of daily stressors or hassles than in indices of major life events. Patients in our sample were, on average, receiving substantial maintenance dosages of neuroleptics. It could be suggested that this might result in our sample being less influenced by stress-related events than if they were on lower dosages of medication. We cannot directly assess this possibility. There is, however, no apparent compelling argument that the effect of medication would be to reduce sensitivity to major life event stressors more than to minor stressors. In addition, it should be noted that the little data that is available favour the hypothesis that patients on neuroleptics actually show a stronger relationship between stressors and the clinical state (Brown and Brown 1970; Leff et al. 1973). Although relationships have been found in the past between major life events and worsening of psychotic symptoms in schizophrenia, there now appear to be strong arguments to be made for the inclusion of measures of comparatively minor day-to-day stressors associated with immediate living circumstances in the study of the influence of stress on schizophrenia. It is worth noting that almost all research on stress and symptomatology in schizophrenia has used a retrospective design which contrasts antecedent stressors for patients who are already known to differ on their "relapse" or symptom status. The only study to use a truly prospective design in that variation in stress is used to predict subsequent symptoms has been reported by Hardesty et al. (1985). Such studies are necessary in order to determine the relative risk associated with increased stressors (Day 1989). Hardesty et al. found a significant relationship for life events predicting only the negative symptoms of withdrawal, but none of the positive symptoms of schizophrenia. A prospective study using standard measures of objectively major life events, minor life challenges, subjective stress and various symptoms associated with schizophrenia would provide important information concerning the influence of stress on the course of schizophrenia. We are currently carrying out such a study.

Discussion It has been suggested a number of times in the literature on schizophrenia that it is more the adaptional demands of day to day life rather than maj or life events that procide sources of stress to patients suffering from schizophrenia (Beck and Worthen 1972; Donovan et al. 1975; Weinberger 1990). As Orrell et al. (1990) have recently suggested in the context of dementia, changes and challenges in daily routine are particularly likely to have an impact on patients suffer-

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Dr. R. M. G. Norman W. M. C. H. Building, Room 126 Community Rehability Program Victoria Hospital 375 South Street London, Ontario N6A 4G5 Canada