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Soc Psychiatry Psychiatr Epidemiol (1991)26:212-216 S o c i a l P s y c h i a t r y an~9 Springer-Verlag 1991 P s y c h i a t r i c E p i d e m i o l o g y

S u b j e c t i v e s t r e s s i n s c h i z o p h r e n i c p a t i e n t s *R . M . G . N o r m a n a n d A . K . M a l l aDepartmen t of Psychiatry,University of Western Ontario and Victoria Hosp ital, London , Ontario, Canad aAccepted: June 26, 1991

S u m m a r y . T h e r e l a t i o n s h i p o f m a j o r l i fe e v e n t s a n d d a i l ys t r e s s o r s t o s u b j e c t i v e s t r e s s w a s i n v e s t i g a t e d i n o u t -p a t i e n t s s u f f e r i n g f r o m s c h i z o p h r e n i a . D a i l y s t r e s s o r s o rh a s s l e s w e r e f o u n d t o b e m o r e p r e d i c t i v e o f s u b j e c t i v es t r es s t h a n w e r e m a j o r l i fe e v e n t s . T h e s e f i n d i n g s w e r e n o ti n f l u e n c e d b y w h e t h e r a c r o s s s e c t i o n a l o r p r o s p e c t i v ea n a l y s i s w a s u s e d . T h e i m p l i c a t i o n s f o r f u t u r e r e s e a r c h o ns t re s s a n d s c h i z o p h r e n i a a r e d i s c u s s e d .

O n e o f th e m a n y c o n t r o v e r s ie s s u r r o u n d i n g t h e d i s o r d e r o fs c h i z o p h r e n i a c o n c e r n s t h e e x t e n t to w h i c h it i s i n f l u e n c e db y p s y c h o s o c i a l s t r es s o r s . C l i n i c i an s w h o t r e a t s c h i z o -p h r e n i c p a t i e n t s o f t e n a s s u m e t h a t s t r e s s d o e s p l a y a si g-n i f i ca n t ro l e i n th e d e v e l o p m e n t a n d c o u r s e o f s y m p t o m s i nt h o s e i n d i v i d u a l s w h o a r e v u l n e r a b l e t o t h e d i s e a s e . T h e r eh a s a l s o b e e n c o n s i d e r a b le s p e c u l a t io n c o n c e r n i n g r e a s o n sw h y in d i v i d u a l s s u s c e p ti b l e t o s c h i z o p h r e n i a m a y b e e s p e -c i a l l y sens i t i ve t o t he e f fec t s o f s tr e ss ( e .g . Sp r ing an dC o o n s 1 9 8 2 ; N u e c h t e r l e i n a n d D a w s o n 1 9 8 4 ; N i c h o l s o na n d N e u f e l d 1 98 9) . I n c o n t r a s t t o t h e p o p u l a r i t y o f s u c h as -s u m p t i o n s c o n c e r n i n g t h e r o l e o f s tr e s s , r e v i e w s o f t h e r e -s e a r c h l i te r a t u r e o n t h e r e l a ti o n s h i p b e t w e e n p s y c h o s o c i a ls tr e ss a n d s y m p t o m a t o l o g y in s c h i z o p h r e n i a h a v e g e n e r -a l ly c o n c l u d e d t h a t t h e e v i d e n c e f o r s u c h a r e l a t i o n s h i p i sv e r y w e a k ( R a b k i n 1 98 0; T e n n a n t 1 98 5) .P a s t r e s e a r c h o n s t r e s s a n d s c h i z o p h r e n i a h a s r e l i e d a l-m o s t e x c l u s i v e l y o n m e a s u r e s o f m a j o r l if e e v e n t s a s a ni n d e x o f s t re s s ( e . g . B r o w n a n d B M e y 1 96 8; C h u n g e t a l.1 98 6; H a r d e s t y e t a l . 1 98 5) . T h i s i s p a r t i c u l a r l y n o t e w o r t h yi n t h e l i g h t o f t w o o b s e r v a t i o n s . T h i s f i rs t is t h e r e p e a t e df i n d in g in r e s e a r c h o n o t h e r d i s o r d e rs a n d s y m p t o m s t h a te v e r y d a y a n d c o m p a r a t i v e l y m i n o r s t re s s o rs o r h a s s le s a r em o r e i m p o r t a n t p r e d i c to r s o f e x p e r i e n c e d s t r es s a n d s y m p -t o m a t o l o g y t h a n a r e m e a s u r e s o f m a j o r l if e e v e n t s ( K a n n e re t a l. 1981 ; M on ro e 1983 ; Za r sk i 1984). T he s econ d i s t he* This research was supported by a grant from the Upjohn Lond onNeurosciences Program. Assistance was also provided by North Ba yPsychiatricHosp ital and Dr. Peter Williamsonand th e staff of the ac-tive treatm ent unit of London Psychiatric Hosp ital.

s u g g e s t i o n f r o m s c h o l a r s i n t e r e s t e d i n b o t h p s y c h o s o c i a la n d b i o l o g i c a l a s p e c t s o f s c h i z o p h r e n i a , t h a t i n d i v i d u a l sw h o s u f f e r f r o m t h i s d i s o r d e r m a y b e p a r t i c u l a r l y l i k e l y t ob e s t r e s s ed i n r e sp o n s e t o m i n o r d e m a n d s f o r a d a p t a t i o nm o r e o f t e n t h a n i n r e s p o n s e t o u n u s u a l a n d m a j o r l i f ec h a n g e s a n d c h a l l e n g e s ( B e c k a n d W o r t h e n 1 97 2; D o n o -v a n , D r e s s l e r a n d G e l l e r 1 97 5; W e i n b e r g e r 1 99 0) .T h e o n l y p u b l i s h e d s t u d y t o e x a m i n e t h e p o s s i b le e f f e c to f b o t h m a j o r a n d m i n o r l i fe e v e n t s o n s c h i z o p h r e n i a i s r e -p o r t e d i n a r e c e n t p a p e r b y M a l l a e t a l . ( 1 9 9 0 ) . I n t h a ts t u d y c a s e r e c o r d s o f a o n e y e a r p e r i o d w e r e e x a m i n e df o r 2 1 s c h i z o p h r e n i c s w h o w e r e b e i n g f o l l o w e d a s o u t -p a t ie n t s . I n f o r m a t i o n w a s a b s t r a c te d f r o m t h e r e c o r d s i no r d e r t o a s s e s s t h e l e v e l s o f m a j o r a n d i n f r e q u e n t l i f ee v e n t s s u c h a s m a r r i a g e s , s e p a r a t i o n s , l o s s o f j o b , p r o m o -t i o n s , d e a t h s o f s i g n i f i c a n t o t h e r s , e t c . a n d a l s o m o r e r e g u -l a r d a y t o d a y c h a l l e n g e s a n d c h a n g e s i n s p h e r e s o f l i f es u c h a s w o r k , s c h o o l , i n t e r p e r s o n a l r e l a t i o n s , e tc . T h e d a t as u g g e s t e d t h a t b o t h t y p e s o f e v e n t s w e r e r e l a t e d t o w o r s -e n i n g c l in i c a l s t a t e . M a l l a e t a l. , c o n c l u d e d t h a t t h e i r r e -s u lt s " p r o v i d e s o m e p r e l i m i n a r y e v i d e n c e f o r t h e i m p o r -t a n c e o f b o t h m a j o r a n d m i n o r l i f e e v e n t s i n r e l a t i o n t or e l a p s e i n s c h i z o p h r e n i a . W e s u g g e s t , t h e r e f o r e , t h a t r e -s e a r c h s h o u l d a d d r e s s l if e e v e n t s o f a l l m a g n i t u d e s t o a s -c e r t a i n t h e i r t r u e r o l e i n s c h i z o p h r e n i a . " U n f o r t u n a t e l y ,b e c a u s e o f t h e n a t u r e o f t h e i r st u d y , M a l l a e t a l. c o u l d n o tp r o v i d e d a t a b a s e d o n s t a n d a r d i z e d m e a s u r e s .

W h a t is t h e r e l at i v e i m p o r t a n c e o f m a j o r v e r s u s c o m -p a r a t i v e l y m i n o r d a i l y s tr e s s o r s a s p r e d i c t o r s o f s u b j ec t i v es t r e s s i n p a t i e n t s s u f f e r i n g f r o m s c h i z o p h r e n i a ? I n t h i sp a p e r w e p r e s e n t t h e f i rs t p u b l i s h e d d a t a r e l e v a n t t o t h isq u e s t i o n u s i n g s t a n d a r d i z e d m e a s u r e s .

M e t h o dSubjectsS u b j e ct s w e r e r e c r u i t e d f r o m t h o s e a t t e n d i n g o u t p a t i e n tc l in i c s a t V i c t o r ia H o s p i t a l o r L o n d o n P s c h i a t r i c H o s p i t a li n L o n d o n O n t a r i o o r N o r t h B a y P s y c h i a tr i c H o s p i t a l in

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213North Bay, Ontario. All patients were interviewed by oneof two experienced psychiatrists using the StructuredClinical Interview for D. S. M. III -R (Spitzer e t al. 1985) toconfirm the diagnosis of schizophrenia. Criteria for inclu-sion in the sample were: having a diagnosis of schizophre-nia; being between the ages of 17 and 60; having had atleast one previous admission to hospital for treatment ofschizophrenia; and having been stabilized on medica tionas outpatients for at least three months prior to entry intothe study. Exclusion criteria were: having organic braindisease or a history of head injury; significant drug or alco-hol dependence; and/or a history of affective disorder.One hundred patients who met these criteria were ap-proached to partic ipate in the study. Of these 100 patients ,it was possible to obtain consent and the necessary infor-mation f rom 95.

Procedure

After providing a general in troduction 1:o the project andobtaining consent, a number of assessments were carriedout with reference to the patients. Demographic informa-tion such as age, gender, mari tal status, ,educational back-ground and employment were recorded on the basis ofchart information and interviews with patients. Totalnumber of admissions for psychiatric treatment and cur-rent neuroleptic medication were recorded from patientcharts and confi rmed with clinicians. Patients were askedto complete three self-report instruments of relevance tothe assessment of stress. These were the Psychiatric Epi-demiology Research Interview (PERI) Life Events Scale(Dohren wend 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 con-cerning major changes in one's life situation such as get-ting married, being fired, changing residences, legal dif-ficulties, illnesses, etc. The items cover many areas of aperson's life including school, work, love and marriage,family, residence, crime and legal matters, finances, socialactivities, health, etc. Respondent s are simply asked to in-dicate whether each of the events listed had occurred tothem for the time period under consideration. In the de-velopment of this instrument Dohrenwen d et al. (1978)took particular care in the selection of items and proce-dures for judging the personal r eadjustmen t likely to beassociated with each item. The PERI Scale formed thebasis for the measure of life event stressors used by Ven-tura et al. (1989) in their sophisticated longitudinal studyof the relationship between stressful life events and in-creases in symp tomatology of schizophrenia.Questions concerning life events were asked with ref-erence to the one month prior to the interview date. Thistime period was selected because past studies have shownthat it is the occurrence of major life events within the im-mediately preceding three to four weeks that appear mostlikely to have an impact on symptoms state of schizo-phrenic patients (Brown and Birley 1968; Day et al. 1987;Ventura et al. 1989).Minor or daily stressors were assessed using the Hass-les Scale (Kanner et al. 1981). This instrument was de-

signed to measure stressors in the form of common every-day difficulties and challenges. It includes items assessingthe reported pressures, problems or difficulties associatedwith such circumstances as "not enough mo ney for cloth-ing", "family responsibilities", "transportation prob-lems", etc. The are a total of 118 items in this scale. Re-spondents are asked to indicate which of the items hasoccurred to them over the previous month, and for thosethat had occurred they are asked to rate on a three pointscale the severi ty of the hassle. Kanner et al. (1981) havefound this scale to have adequate levels of test-retest reli-ability, and, as previously noted , a number of investigatorshave found the Hassles Scale to be more predictive of laterpsychological and physical symptoms than measures ofmajor life events using samples from several populationsother than patients suffering from schizophrenia (Kanneret al. 1981; Mon roe 1983; Zarski 1984).Both the PERI Scale and the Hassles Scale have in pastresearch been scored in two ways. One meth od of scoringis simply to count the number of items endorsed by the re-spondent - i. e., how many major life events or how manyhassles does the subject report having experienced. In thesecond method of scoring each item is weighted by anindex of the stress associated with it. In the case of thePERI Scale this weighting is based on estimates carefullyelicited during the scale construction from independentjudges of the amount of personal readjustment that wouldtypically be required in response to the event (Dohren-wend et al. 1978). In the case of the Hassles Scale theweighting is based on the respondents own ratings of theseverity of the hassles endorsed. The procedure used inthe Hassles Scale has been particularly contentious be-cause of the probable confounding of external stressorswith the subjective stress response (cf. Dohrenwend andShrout 1985; Lazarus et al. 1985). Reich et al. (1988) havepresented evidence to support the use of the simple num-ber of items endorsed on the Hassles Scale as a measure ofexternal minor stressors independe nt of subjective reac-tion. For this reason, and because simple number count onthe P ERI has been used successfully in past research onlife events and symptomatology in schizophrenia, it wasinitially decided to use n umber of items endorsed as theprimary 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 inorder to provide a psychometrically sound global measureof perceived stress. It is designed to measure the exten t towhich respondents find their lives stressful (i. e. subjec-tively overloading, unpredictable, and uncontrollable).Typical items ask respondents to indicate on a five pointscale how often during the past month they have "beenupset because of something that happened unexpected-ly?" or " found that you could not cope with all the thingsthat you had to do?". One of the primary reasons for thedevelopment of the PSS was to provide an index ofgeneral experienced level of stress that could be used as anoutcome measure for assessing the effects of various typesof stressful events. The PSS has shown adequate levels ofinternal reliability. The PSS has been found to have con-struct validity as a measure of stress which is related tovarious indicators of life events, psychological distress,

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214Table 1. M eans and standard deviations o f me asuresMeasure Mean s.d.PE R I Scale 1.0 1.2Hassles Scale 43.2 43.0Perceived Stress Scale (PSS) 22.6 8.4

Table 2. Correlations of PE R I and Hassles Scales with PerceivedStress ScaleMeasure Correlationwith PSSA. P ER I Scale (unweighted)B. Hassles Scale (unweighted)C. PER I Scale (weighted)D. Hassles Scale (weighted)E. A verage Severity of HasslesEach scale divided by rated levelof symptom independence of items:E H igh Ind. PER1 itemsG. Low Ind . PERI i temsH. H igh Ind. Hassles i temsI. Low Ind. Hassles i tems

0.150.38**0.140.46**0.24*

0.070.24*0.42**0.32**

* P

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215c a r r i e d o u t u s i n g f iv e p o i n t s c al e s . T h e r e w a s a n a v e r a g ec o r r e l a ti o n o f 0. 72 b e t w e e n t h e s e j u d g e m e n t s a c r o s s p s y -c h i a tr i s ts . T h e m e a n o f t h e r a t i n g s f o r e a c h i t e m w a s u s e da s t h e i n d e x o f t h e l i k e l y d e g r e e o f s y m p t o m i n d e -p e n d e n c e o f t h e s t r es s o r . O n e a c h s c a l e a m e d i a n s p li t o fi t e m s w a s c a r r i e d o u t o n t h e b a s i s o f t h e i r r a t e d l e v e l o fs y m p t o m i n d e p e n d e n c e . T h e t o t a l s c o r e o n e a c h s p l it h a lfo f b o t h t h e P E R I a n d H a s s l e s S ca l es w a s t h e n c o r r e la t e dw i t h t h e P S S . R e s u l t s a r e p r e s e n t e d i n th e l o w e r p a r t o fT a b l e 2 . T h e r e w a s n o s i g n i f i c a n t d i f f e r e n c e i n t h e c o r r e l a -t i o n o f h i g h a n d l o w i n d e p e n d e n t H a s s l e s i t em s w i t h s u b -j ec t i ve s t r e ss ( r = 0 .42 and 0 .32 r e spec t i ve ly , P < 0.001 fo rb o t h ) . F o r t h e P E R I S c a l e , h o w e v e r , w h e n u s i n g t h o s ei t e m s j u d g e d r e l at i v e ly lo w o n s y m p t o m - i n d e p e n d e n c ethe r e w as a s i gn i f i can t co r re l a t i on ( r = 0 .24 , P < 0 .01) , bu tn o t w h e n u s i n g i t e m s h i g h i n i n d e p e n d e n c e ( r = 0 .0 7, n . s ,) .I t m i g h t b e a r g u e d t h a t t h e o n e m o n t h p e r i o d w i t h re f -e r e n c e t o w h i c h m a j o r l i f e e v e n t s h a s b e e n a s s e s s e d w a st o o b r i e f a t i m e t o d e t e c t m a j o r e v e n t s t h a t m i g h t b e i n -f l u e n c i n g s u b j e c t iv e s t r e s s. A s n o t e d e a r li e r, t h e o n em o n t h p e r i o d w a s s e l e c te d b e c a u s e o f p as t f i n d in g s t h a t i ta p p e a r s t o b e l i fe e v e n t s f o r a n a n t e c e d e n t p e r i o d o f t h r e et o f o u r w e e k s t h a t a r e m o s t l i k e ly to h a v e a n e f f e c t o n t h ec l in i c a l s t a t e o f p a t i e n t s w i t h s c h i z o p h r e n i a . N e v e r t h e l e s s ,t o c h e c k o n t h e p o s s i b i l i t y t h a t w e m i g h t b e m i s s i n g t h e e f -f e c ts o f m o r e d i s t a l e v e n t s o n p e r c e i v e d s t r es s a d d i t i o n a ld a t a w a s s u b s e q u e n t l y c o l l e c t e d o n 5 0 i n d i v i d u a l s f r o mt h e o r i g i n a l s a m p l e . O n e o f t h e p u r p o s e s o f t h i s a d d i t i o n a ld a t a c o l l e c t io n w a s t o e x a m i n e t h e e f f e c t s o f m a j o r l i fee v e n t s o v e r a s ix m o n t h p e r i o d o n p e r c e i v e d s t r e ss .A l t h o u g h r e s e a r c h e r s i n t h e p a s t h a v e a s s e s s e d l i f ee v e n t s w i t h r e f e r e n c e t o p e r i o d s o f t im e m u c h l o n g e r t h a no n e m o n t h , t h e r e i s e v i d e n c e t h a t t h e r e l ia b i l i ty o f re c a l l o fe v e n t s f o r s u c h l o n g t i m e p e r i o d s i s u n s a t i s f a c t o r y ( N e u -g e b a u e r 1 98 3; K l e i n a n d R u b o v i t s 1 9 8 7) . F o r t h i s re a s o n ,r a t h e r t h a n s i m p ly a s k i n g f o r o n e r e t r o s p e ct i v e r e p o r t o fl if e e v e n t s c o n c e r n i n g a l o n g e r p e r i o d o f t i m e , w e c a r r i e do u t a s s e s s m e n t s o n a m o n t h l y b a s i s f o r s ix m o n t h s u s i n gt h e P E R I S c a l e , t h e H a s s l e s S c a l e a n d t h e P S S . W e t h e nc a l c u l at e d t h e a v e r a g e f o r e a c h o f t h e s ix m o n t h s o n b o t ht h e P E R I a n d t h e H a s s l e s S c a le t o p r e d i c t p e r c ei v e d s t r es sa t t h e t i m e o f t h e f i n a l a s se s s m e n t . T h e r e s u l t s u s i n g t h i sa d d i t i o n a l d a t a w e r e s i m i la r to t h o s e b a s e d o n d a t a f o r ao n e m o n t h p e r i o d . F o r i n s t a n c e, t h e c o r r e l a ti o n b e t w e e nt h e u n w e i g h t e d P E R I S c a l e a n d t h e P S S w a s 0 .0 2 ( n. s .)a n d f o r t h e H a s s l e s S c a l e it w a s 0 .4 7 ( P < 0 . 0 0 1 ) . I n am u l t i p le r e g r e s s i o n o n t h i s s ix m o n t h d a t a o n l y t h e H a s s l e ss c a le w a s f o u n d t o c a r r y a s i g n i f ic a n t w e i g h t i n th e p r e d i c -t i o n o f p e r c e i v e d s t r es s .

Di scu s s i on

I t h a s b e e n s u g g e s t e d a n u m b e r o f t i m e s in t h e l i t e ra t u r e o ns c h i z o p h r e n i a th a t i t is m o r e t h e a d a p t i o n a l d e m a n d s o f d a yt o d a y l i f e r a t h e r t h a n m a j o r li f e e v e n t s t h a t p r o c i d e s o u r c e so f s tr e s s t o p a t i e n t s s u f f e r i n g f r o m s c h i z o p h r e n i a ( B e c ka n d W o r t h e n 1 97 2; D o n o v a n e t a l . 1 97 5; W e i n b e r g e r 1 99 0) .A s O r r e l l e t a l . (1 9 9 0) h a v e r e c e n t l y s u g g e s t e d i n t h e c o n -t e x t o f d e m e n t i a , c h a n g e s a n d c h a l le n g e s i n d a i l y r o u t i n ea r e p a r t i c u l a r l y l i k e l y t o h a v e a n i m p a c t o n p a t i e n t s s u f f e r -

i n g f r o m c o g n i t i v e i m p a i r m e n t s . S p r i n g a n d C o o n s i n 1 98 2s u g g e s t e d t h a t e m p i r i c a l s u p p o r t b e s o u g h t f o r th e c l i n ic a lo b s e r v a t i o n t h a t p a t i e n t s w i t h s c h i z o p h r e n i a a r e o f t e ns t r o n g l y e f f e c t e d b y s u b j e c t i v e l y t r a u m a t i c , b u t o b j e c t i v e l yt r iv i a l ev e n t s . T h e w o r k o f M a l l a e t a l . (1 9 9 0) a n d t h e r e s u l t so f th i s p a p e r s u g g e s t t h a t c o m p a r a t i v e l y m i n o r d a i l y st r e s -s o r s d o i n d e e d h a v e a s i g n i fi c a n t e f f e c t o n s u c h p a t i e n t s .T h e c u r r e n t s t u d y s h o w s t h a t t h e r e l a ti o n s h i p b e t w e e nd a i l y h as s l e s a n d s u b j e c t iv e s t re s s i s g r e a t e r t h a n t h a t b e -t w e e n m a j o r l i f e e v e n t s a n d s u b j e c t i v e s t r es s .O u r f i nd i n g s s u p p o r t t h e c o m m o n c l i ni c al i m p r e s s i o nt h a t p a t i e n t s w i t h s c h i z o p h r e n i a c a n p e r c e i v e t h r e a t i nc h a ll e n g e s o r c h a n g e s t h a t m i g h t b e s e e n b y o t h e r s a s c om -p a r a t i v e l y m i n o r . T h e r e s u l t s a r e a l s o c o n s i s t e n t w i t h e v i-d e n c e t h a t t h e e m o t i o n a l t o n e o f a p a ti e n t 's i m m e d i a t e e n -v i r o n m e n t m a y b e a n i m p o r t a n t p r e d i c t o r o f l i k e li h o o d o fr e l a p s e . F o r i n s t a n c e , i t a p p e a r s l i k e l y t h a t f a m i l y c h a r a c -t e r is t i c s s u c h a s " e x p r e s s e d e m o t i o n " o r ~ ' c o m m u n i c a t i o nd e v i a n c e " w h i c h a r e c o m m o n l y im p l i c a t e d in l i k e l ih o o dof r e l apse (Brown e t a l . 1972 ; Mik lowi t z e t a l . 1986 ;V a u g h n e t a l . 19 84 ) a r e m o r e l i k e l y t o b e r e f l e c t e d i nm e a s u r e s o f d a i l y s t r e s s o r s o r h a s s l e s t h a n i n i n d i c e s o fm a j o r l i f e e v e n t s .P a t i e n t s i n o u r s a m p l e w e r e , o n a v e r a g e , r e c e i v i n g su b -s t a n t i a l m a i n t e n a n c e d o s a g e s o f n e u r o l e p t i c s . I t c o u l d b es u g g e s t e d t h a t t h i s m i g h t r e s u l t i n o u r s a m p l e b e i n g l e s si n f l u e n c e d b y s t r e ss - r e la t e d e v e n t s t h a n i f t h e y w e r e o nl o w e r d o s a g e s o f m e d i c a t i o n . W e c a n n o t d i r e c t l y a s s e sst h i s p o ss i b il it y . T h e r e i s, h o w e v e r , n o a p p a r e n t c o m p e l l i n ga r g u m e n t t h a t t h e e f f e c t o f m e d i c a t i o n w o u l d b e t o r e d u c es e n s i t iv i t y t o m a j o r l i fe e v e n t s t r e s s o r s m o r e t h a n t o m i n o rs t r es s o r s . I n a d d i t i o n , i t s h o u l d b e n o t e d t h a t t h e l i tt l e d a t at h a t i s a v a i l a b l e f a v o u r t h e h y p o t h e s i s t h a t p a t i e n t s o nn e u r o l e p t i c s a c t u a l l y s h o w a s t r o n g e r r e l a t i o n s h i p b e -t w e e n s t r es s o r s a n d t h e c l in i c a l s t a t e ( B r o w n a n d B r o w n1970; Le ff e t a l . 1973).

A l t h o u g h r e l a t i o n s h ip s h a v e b e e n f o u n d i n t h e p a s t b e-t w e e n m a j o r l if e e v e n ts a n d w o r s e n i n g o f p s y c h o t i c s y m p -t o m s i n s c h i z o p h re n i a , th e r e n o w a p p e a r t o b e s t r o n g a r -g u m e n t s t o b e m a d e f o r t h e i n cl u s io n o f m e a s u r e s o fc o m p a r a t i v e l y m i n o r d a y - t o - d a y s t r e ss o r s a s s o c i a t e d w i t hi m m e d i a t e l i v i n g c i r c u m s t a n c e s i n t h e s t u d y o f t h e i n -f l u e n c e o f s t re s s o n s c h i z o p h r e n i a . I t is w o r t h n o t i n g t h a ta l m o s t a l l r e s e a r c h o n s t r es s a n d s y m p t o m a t o l o g y i n sc h i -z o p h r e n i a h a s u s e d a r e t ro s p e c t i v e d e s i g n w h i c h c o n t r a s t sa n t e c e d e n t s t r e s so r s f o r p a t ie n t s w h o a r e a l r e a d y k n o w nt o d i f f e r o n t h e i r " r e l a p s e " o r s y m p t o m s t a tu s . T h e o n l ys t u d y t o u s e a t r u l y p r o s p e c t i v e d e s i g n i n t h a t v a r i a t i o n i ns t re s s is u s e d t o p r e d i c t s u b s e q u e n t s y m p t o m s h a s b e e n r e -p o r t e d b y H a r d e s t y e t a l . ( 1 98 5 ). S u c h s t u d i e s a r e n e c e s -s a r y in o r d e r t o d e t e r m i n e t h e r e l a t i v e r is k a s s o c i a t e d w i t hi n c r e a s e d s t r e s s o r s ( D a y 1 98 9) . H a r d e s t y e t a l . f o u n d a s i g-n i f i c a n t r e l a t i o n s h i p f o r l i f e e v e n t s p r e d i c t i n g o n l y t h e n e -g a t iv e s y m p t o m s o f w i t h d r a w a l , b u t n o n e o f th e p o s i t i v es y m p t o m s o f s c h i z o p h re n i a . A p r o s p e c t iv e s t u d y u s i n gs t a n d a r d m e a s u r e s o f o b j e c ti v e ly m a j o r l if e e v e n ts , m i n o rl i fe c h a l le n g e s , s u b j e c t i v e s t re s s a n d v a r i o u s s y m p t o m s a s -s o c i a te d w i t h s c h i z o p h r e n i a w o u l d p r o v i d e i m p o r t a n t i n -f o r m a t i o n c o n c e r n i n g t h e i n f l u e n c e o f s tr e ss o n t h e c o u r s eo f s c h i z o p h r e n i a . W e a r e c u r r e n t l y c a r r y i n g o u t s u c h as tudy .

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21 6Re fe r enc e sBeck J , W or then K (1972) Prec ip i t a t ing st r e s s c r i s is t heory , and ho s -p i t a l i z a ti on in s c h i z oph r e n i a a nd de p r e s s i on . A r c h G e n Ps yc h i a t26 : 123 - 129B i r l e y JL T , B r ow n G W ( 1970) C r i s e s a nd l i f e c ha nge s p r e c e d i ng t heonse t or r e l ap se of acute s chizophren ia : c l in i ca l a spec t s . Br J Psy-chia t ry 116:327-333B r ow n G W , B i r l e y J L T ( 1968 ) C r i s e s a nd l i fe c ha nge s a nd t he on s e t

o f s c h iz oph r e n i a . J H e a l t h Soc B e h a v 9 : 203 - 214B r ow n G W , B i r l e y J L T , W i ng J K ( 1972 ) I n f l ue nc e o f f a m i l y l if e ont he c ou r s e o f s c h i z oph r e n i a d i s o r de r s : a r e p l i c a ti on . B r J P s c h i a t r y121:241-258C hung R R , L a nge l udd e c ke R T e nna n t C ( 1986 ) T h r e a t e n i ng l i f ee ve n t s i n t he ons e t o f s c h i z oph r e n ia , s c h i z oph r e n i f o r m ps yc hosi sand h ypom ania . Br J Psychia t ry 148:680q585C ohe n S , K a m a r c k T , M e r m e l s t e in R ( 1983 ) A g l oba l m e a s u r e o fpe r c e i ve d s t re s s . J H e a l t h Soc B e ha v 24 : 385 - 396Coh en S, Wi l l i amson G (1988) Pe rce ived s t r e s s in a pro bab i l i t ys a m pl e o f t he U n i t e d S t a t e s. I n : Spa c a pa n S , O s ka m p S ( e ds ) T heSoc i a l P s c ho l ogy o f H e a l t h . Sa ge , N e w bu r g P a r kCohen S, Lichtens t e in E (1990) Pe rce ived s t r e s s , qui t t i ng smokinga nd s m ok i ng r e l a ps e . H e a l t h Ps yc ho l 9 : 466 -478D a y R , N i e l so n J A , K o r t e n A , E m b e r g G , D u b e K C , G e b h a r t J,J a b l e ns ky A , L e o n C , M a r s e l l a A , O l a t a w ur a M , Sa r t on i u s N ,S t r om a g r e n E , T a ka he s l i R , W i g N , W yn ne L C ( 1987 ) S t re s s f u ll i f e event s preceding the acute onse t of s chizophrenia : a c ros s -na t i ona l s tudy f r om t he W or l d H e a l t h O r ga n i z a t i on . C u l t M e dPs yc h i a t r y 11 : 123 -205D a y R ( 1989 ) Sc h i z oph r en i a . I n : B r ow n G W , H a r r i s T O ( e ds ) L i f eE ve n t s a nd I l l ne ss . G u i l f o r d , N e w Y or kD o h r e n w e n d B S , K r a s n o f f L , A s k e n a s y A R , D o h r e n w e n d B P(1978) Ex em pl i f i ca t ion of a m e tho d fo r s ca l ing l i f e event s : t hePE R I l i fe e ve n t s sc a le . J H e a l t h Soc B e ha v 19 : 205 - 229D on ova n J M , D r e s s l e r D M , G e l l e r R A ( 1975) Ps c h i a t r i c c ri si s: ac om pa r i s on o f s c h i z oph r e n i c a nd nons c h i z oph r e n i c pa t i e n ts . JN e r v M e r i t D i s 161 : 172 - 179G l a s gow R F , K l e s ge s R C , M i z e s J S , Pe c ha c e k T F ( 1985) Q u i t t i ngs m ok i ng s t r a te g i e s u s e d a nd v a r i a b l e s a s s oc ia t e d w i th s uc ce s s i n as t op - s m ok i ng c on t e s t . J C ons u l t C l i n Ps yc ho153 : 905 - 912H a r d e s t y J , Fa l l oon I R H , S h i r in K ( 1985) T he i m pa c t o f l if e e ve n t s .S t r e s s a nd c op i ng on t he m or b i d i t y o f s c h i zoph r e n i a . I n : Fa l l oonI R H e t a l. ( e d s ) Fa m i l y M a na ge m e n t o f Sc h i z oph r e n i a : a S t udy o fC l i n ic a l , Fa m i l y a nd E c on om i c B e ne f it s . Johns H op k i ns U n i ve r -s ity , Ba l t im oreK a nn e r A D , C oy ne JC , Sc ha e f e r C , L a z a r us R S ( 1981 ) C om pa r i s onso f t w o m od e s o f s t re s s m e a s u r e m e n t : da i l y ha s s le s a nd up l i f t s ve r -s u s m a j o r l i fe e ve n ts . J B e ha v M e d 4 : 1 - 39K l e i n D N , R u bov i t s D R ( 1987) T he r e l i a b i l i tyo f s ub j e c t s ' re po r t s onl i f e event s inven tor i e s : a l ongi tudina l s tudy. J B ehav M ed 10: 501-51 2L e f t J, H i r s c h S , G a i n d R , R hod e R S t e ve ns B ( 1973 ) L i f e e ve n t s a ndm a i n t e na nc e t he r a py i n s c h i z oph r e n i c r e l a pse . B r J P s yc h i a t r y123:659-660M a l l a A K , C or t e s e L , Sha w T S , G i ns be r g B ( 1990 ) L i f e e ve n t s a ndr e l a ps e i n s c h i z oph r e n i a : a one ye a r p r o s p e c t i ve s tudy . Soc Ps y -c h i a t r y Ps yc h i a t r E p i de m i o125 : 221 - 224

M i k l ow i t z D J , S tr a c ha n A M , G o t ds t e i n M J, D o a ne J A , Snyde r R S ,H o g a r t y G E , F a l l o o n I R H ( i9 8 6 ) E x p r e s s e d em o t i o n a n d c o m -m un i c a t i on de v i a nc e in t he f a m i l ie s o f s c h i zoph r e n i cs . J A b nor mPs yc ho195 : 60 - 66M o nr oe SM ( 1983) M a j o r a nd m i no r l i fe e ve n ts a s p r e d i c t o r s o f p s y -chologica l d i s t r e s s : fur the r i s sues and f indings . J Behav Med 6:189-205N e ug e ba ue r R ( 1983 ) R e l i a b i l i t y o f l i f e e ve n t i n t e r v i e w s w i th ou t -pa t i e n t s c h i z oph r e n ic s . A r c h G e n Ps yc h i a t r y 40 : 378 - 383N i c ho l s on I R , N e u f e l d R W J ( 1989 ) Fo r m s a nd m e c ha n i s m s o f s u s-c e p t i b i l it y t o s t r e s s in s c h i z oph r e n i a . I n N e u f e l d R W J ( e d ) A d -vances in the In ves t iga t ion of Psycho logica l St r e s s . John W i ley &Sons , N e w Y or kN o r m a n R M G , M a l l a A K ( in p r e ss ) D y s p h o r i c m o o d a n d s y m p t o -m a t o l og y i n s c h i z oph r e n ia . P s yc ho l M e dN ue c h t e r l e i n K H , D a w s on M E ( 1984) I n f o r m a t i on p r oc e ss i ng a nda t t e n t i ona l f unc t i on i ng i n t he de ve l opm e n t a l c ou r s e o f s c h i z o -ph r e n i c d i s o r de r s. Sc h i z oph r B u l l 10 : 160 - 203O r r e l l M W , B e r gm a n K , E l t on N , O ' B r i e n J , B e bb i ng t on PE ( 1990 )Li fe event s : t he r e l i abi l i t y of r a t ing changes in rout in e and envi -r onm e n t . Soc Ps yc h i a t r y Ps yc h i a t r E p i de m i o1 25 : 30 440 7Ra bkin J G (1980) St r e s s ful l i f e event s and schizophren ia : a r eview oft he l i t e ra t u r e . P s yc ho l B u l l 87 : 408 - 425R e i c h W P, Pa r r e l l a D R F i l s t e a d W J ( 1998) U nc onf oun d i ng t heHass l e s Sca le : exte rn a l sources ve r sus in t e rna l r e spon ses to s t r e s s .J B e ha v M e d 11 : 239 -249Sp i t z e r R L , W i l l i a m s J B W , G i bbo n M ( 1985) I n s t r uc t i on M a n ua l f o rt he S t r uc t u r e d C l i n i ca l I n t e r v i e w f o r D SM - I I I - R ( SC I D ) . B i o -m e t r i c s R e s e a r c h D e p a r a t m e n t , N e w Y or k S t a t e Ps yc h i a tr i c I n -s t i tu t e , N e w Y or kSpr ing B, Co ons H (1982) St r e s s a s a precur s or of s chizophrenia . In :N e uf e l d R W J ( e d ) Ps yc ho l og i c a l S t r e ss a nd Ps yc hopa t ho l ogy .M c G r a w H i l l , N e w Y o r kTennant C (1985) St r e s s and schizophrenia : a r eview. In t egr Psy-chia t ry 3 :248-261V a ughn C E , Snyde r K S , J one s S , F r e e m a n W B , Fa l l oon I R H ( 1984 )Fam i ly f ac tor s in s chizoph renic r e l apse : r epl i ca t ion in Ca l i forniao f t he B r i t i s h r e s e a r c h on e xp r e s s e d e m o t i on . A r c h G e n Ps y -chia t ry 41:1169-1177V e n t u r a J , N ue c h t e r l e in K H , L uko f f D , H a r de s t y J P ( 1989 ) A p r o -spec t ive s tudy o f s tr e s s ful li f e event s and sc hizoph renic r e l apse . JAbnorm Psycho198: 407-411W e i nb e r ge r D R ( 1990) T he ne u r oa na t om y o f s c h i z oph r e n i a. Pa pe rp r e s e n t e d a t Sc h i z oph r e n i a 1990 : a n I n t e r na t i ona l C onf e r e nc e ,V a n c o u v e rZa r ski J J (1984) Hass l e s and hea l th : a r epl i ca t ion. He a l th P sychol 3 :243-251

D r . R . M . G . N or m a nW . M . C . H . B u i l d ing , R o om 126C o m m u n i t y R e h a b i l i t y P r o g r amV i c t o r i a H os p i t a l375 Sou t h S t r e e tL o n d o n , O n t a r ioN 6 A 4 G 5C a n a d a