The cause of life events in neurosis

Journal of Psychosomatic Research,

THE

CAUSE

Vol.

22, pp.

41 to 45. Pergamon

OF LIFE

EVENTS

CHRISTOPHER TENNANT~ (Received

Press,

1978,

Printed

in Great

Britain

IN NEUROSIS*

and GAVIN ANDREWS$

9 August

1977)

Abstract--Scalings of the relative importance of chance, the behaviour of the subject and the behaviour of others in determining life events were applied to the life events experienced by a group of 150 neurotic subjects and to the events experienced by a carefully matched group of 150 non-neurotics. No consistent differences in the cause of the life events experienced by the two groups could be determined. THE ASSOCIATIONbetween

life-event stress and the onset of both physical and psychological illness is well documented [ 1, 21. One important issue has, however, been largely ignored. This concerns the role each subject may play in the life events he experiences and whether or not this has any influence on his illness risk. In most studies, it has been tacitly assumed that the occurrence of stressful events was fortuitous, the individual concerned having no influence or control over their onset or termination. Each subject is simply regarded as a passive target for events. This situation is certainly so in natural catastrophes, but such events are rare, and in the majority of life experiences the individual is actively involved in the onset and termination of the event. In neurosis, particularly, interpersonal stress has always been considered to be of great aetiological importance. Interpersonal events such as divorce, clearly involve both the subject and other people in his social environment, and the element of chance would appear to play a limited role. Such ideas of the cause of stressful events are flmdamental in the management of neurosis. Both crisis support and the brief psychotherapies focus on identifying the cause of stressful events and mobilizing external social support and internal coping mechanisms to ameliorate the effect of the stressful event. The role of the individual in relation to these events is therefore of interest. In early life-event research there was evidence that some life events, recorded by questionnaire procedure, could also be viewed as changes in behaviour indicative of the early symptoms of illness. Consequently. Brown [3-51 excluded from consideration events considered to have been a direct consequence of the subject’s own behaviour. Both Brown and his colleagues in studies of schizophrenia and depression, and Myers et al. [6] in a study of neurotic impairment, categorised events as being either ‘independent’ or ‘possibly independent’ of the patient’s control. In both studies the two categories of events were separately related to the onset of illness. Fontana et al. [7] in a study of life events and coping style preceding psychiatric hospitalization showed that patients. when compared to normal controls, had an increasing frequency of life events in the year preceding hospitalization. They suggested that most of these excess events were contingent upon the patient’s own behaviour, and that often patients had actively initiated such events, or even engineered

*From the Urban Psychiatry Research Group, University Hospital, Little Bay, N.S.W. 2036, Australia. iResearch Fellow, N.S.W. Institute of Psychiatry. $Associate Professor of Psychiatry.

of New South

Wales,

Prince

Henry

42

CHRISTOPHER TENNANTand GAVIN ANDREWS

the event by provoking others. Paykel et al. [8] used a different but still arbitrary categorisation of events, ‘controlled’ and ‘uncontrolled’, and found that events beyond the patient’s control were more common in hospitalized suicide attempters and depressives, than in well persons in the community. In all these studies, the authors have simply dichotomised life events, and the disparate findings are to some extent a function of differing categorisations of the same events. Such an approach is not ideal, and may result in the loss of potentially useful information. The present authors [9] have suggested that in terms of their aetiology, life events are not simply either contingent or non-contingent, but that they occur as a result of the interaction of a number of aetiological factors. Three broad factors are proposed as relevant to the causation of events: the element of chance, the behaviour of the subject, and the behaviour of significant others. It is assumed that these three factors act differentially for different events. Using the earlier examples, a natural catastrophe would be primarily caused by the element of chance, while arguments could be equally attributed to the behaviour of the subject and to that of significant others. For brevity, these aetiological or contingency factors will be referred to as Chance, Self and Others. The present paper examines the role of Chance, SelJ’and Others in the precipitation of life events associated with neurosis. METHODS A life-event inventory was constructed in the same fashion as described by Fontana et al. [7]. After pilot testing, items were weighted by 151 well persons for their ‘likelihood in causing emotional distress to the average person’. The mean of these weightings constituted the distress scalings for each item. Such scalings allowed an individual’s life-event experience to be summed and compared with that of another. The full inventory and scalings have been published elsewhere [lo]. The extent to which each event in this life-event inventory might be caused by the action of C/larfce, Self or Ofhers was determined by a further consensual scaling exercise. A sub-sample of the above group of well persons (II = 105) was asked to scale the 67 life-event items according to the degree to which the three aetiological factors of Chance, Self and Others might contribute to the occurrence of each event. A total of 10 points was available for allocation to each life event item and raters were asked to apportion these points to each of the three aetiological factors, in proportion to the degree to which each factor was considered to be responsible for the occurrence of that event to the average person. The mean group scalings for each of the three factors for all life-event items was calculated [9]. The scalings differ for each item but trends in groups of items are evident. For example, work, financial and legal problems are seen to be due predominantly to one’s own behaviour, e.g. the scaling for ‘moderate financial difficulties’ are: Chnnce 2.7. Self4.7, Others 2.6. Family and social problems were usually attributed to the behaviour of oneself and tb the behaviour others. ‘Increasing arguments with spouse’, for example, was scaled as follows: Chance 0.6, Self 4.9, Others 4.5. Health and bereavement experiences are attributed largely to chance. ‘A serious physical illness’ had the following scale values: Chance 6.4, Self‘2.2, Others 1.4. A community mental-health survey was carried out in suburban Sydney [ll]. A one in eight random sample of households was enumerated and all adults aged 20-69 years were asked to participate. Of those approached, 90 % (863 subjects) were cooperative. Neurotic impairment was assessed using the General Health Questionnaire (GHQ) 1121.This scale has been shown to be clinically valid in the U.K., U.S.A. [13]gnd Australia [14]. & ihe_Australian validation study,of those subjectsindependently diagnosed as neurotic by a psychiatrist, 80% were correctly identified by the GHQ as impaired, while 94% of those diagnosed as psychologically well were correctly identified by the questionnaire. In this survey, the life-events experience of the respondents was assessed using the self-administered inventory of life events in which respondents were asked whether or not they had experienced these events in the previous year. The one-year cumulative distress score and one-year cumulative contingency scores for Chance, Self and Others for the events experienced were calculated for each subject. Since the number and type of life events experienced is influenced by sociodemographic status, the

of

43

The cause of life events in neurosis

influence of age, sex, marital status and social class was controlled by carefully matching impaired subjects (GHQ score 4-20) with unimpaired subjects (GHQ score O-3), that is, subjects were matched for sex, marital status and social status and were matched for age within a range of five years. Fontana et al. [7] had suggested that events preceding psychiatric hospitalization were largely engineered directly or indirectly by the subject in an attempt to cope with his illness, and that ultimately, these events provoked hospital admission. This excess of events may, therefore, have been caused by factors quite dissimilar to events experienced by normal controls. In the present community study, subjects were not patients per se, yet many were psychologically impaired and a significant correlation betwen neurosis and life-events experience had been demonstrated [15]. Before considering the possible cause of life events in neurosis, it seemed important to compare normal and neurotic subjects who had experienced similar amounts of cumulative life event stress. One hundred and fifty of the 655 normal subjects (mostly those with mean and above-mean scores) were thus matched for their one-year cumulative distress score, with a range of f 10% of the neurotic subjects’ score. The life-event experience of the 150 of the 208 neurotic subjects was more representative of the total neurotic sample, although some neurotic subjects with extremely high scores could not be matched with normals. When subjects were matched in this way, the cumulative distress experienced by each subject, attributable to each of the three aetiological factors, was calculated by applying the contingency scalings to his life-event experience. RESULTS Twenty-four % of the population returned GHQ scores in the impaired range and it was possible to match 150 of these 208 subjects with non-neurotic subjects in the manner described. Since pairs were not identically matched for either age or one-year cumulative distress score, means for the two groups were compared. The mean ages for the psychologically impaired and unimpaired groups were 41.1 years and 40.9 years, respectively, while the mean distress scores were 33.7 in both instances. The groups were considered to be well matched for the designated variables. For each subject, the events reported in the previous year were identified and their contingency scalings summed to give a mean Chance, a mean Self and a mean Others score. This represented for each individual the extent to which the totality of the event experienced in the previous year might be attributed to these factors. The mean group scores for neurotics and non-neurotics were calculated and are displayed in Table 1. There were no differences in the importance of these factors in the two groups by Student’s t-tests. It is possible that the two groups might be experiencing events of a different nature and significance and that the events formative in neurosis might be different from the events experienced by the nonneurotic subjects: for example, the Self component of a ‘divorce’ is probably more strongly associated with neurosis than the equivalent Selfcomponent of ‘minor financial difficulty’, although both contribute the same to the simple cumulative scalings illustrated in Table 1. Accordingly, the individual Clrmzce, Self and Others scalings for an event were multiplied by the significance scalings, to determine the degree of stress occasioned by each of the three aetiological factors determining that event. Each individual’s combined distress/contingency scores were calculated and the mean group scores computed and compared. The results are displayed in Table 2. No differences were evident in the scores of the two groups. TABLE

I.---MEAN

SCORES

FOR

CUMULATIVE Chance, Self, AND EXPERIENCED IN PREVIOUS YEAR

Group

Neurotics

Non-neurotics

Chance Self Others

150 10.9

150 10.7 11.8 8.1

11.0 8.4

Others

SCALINGS

OF EVENTS

t-test N.S. N.S. N.S.

DISCUSSION

In the light of the other studies which have demonstrated an association between types of life events and psychological illness, it is somewhat surprising that in the present study no differences were found between neurotic and non-neurotic groups. Consensus scalings, although a convenient tool in life-events research, are by no

44

CHRISTOPHERTENNANT and GAVIN ANDREWS

TABLE Z.-MEAN

SCORES FOR CUMULATIVEDISTRESS ATTRIBUTABLETO Clrar7c~~,Self AND Othm

FOR EVENrS EXPERIENCED IN PREVIOUS YEAR Group If Chance distress Self distress Others distress

Neurotics

Non-neurotics

150 152.2 95.8 89.0

150 152.8 94.8 83.4

t-test N.S. N.S. N.S.

means as sensitive as an individual’s personal scalings. For instance, the involvement of one subject in a particular event may be substantially different from the involvement of another subject in a similar event. this being attributable to both differences between individual subjects and to differences between the social context of similar events experienced by them. The sensitivity of consensus contingency scalings for any individual under such circumstances is thus likely to be quite low. A fLIrther problem can be attributed to the method used in constructing the original contingency scalings. Asking persons to apportion ten points between ihe three factors means that the scaling of one factor can be predicted from the scalings of the other two, thus producing a complex interdependence between the scores. A further factor likely to obscure any actual relationship between SC(~ and Others caused events and neurosis, is that life-event stress is important in precipitating only a quarter of the cases of neurotic illness [16]. For those persons decompensating under the weight of constitutional or personality factors, the cause of the life events experienced may be irrelevant to their illness status [17]. Despite the limitations mentioned above, the present study attempted to demonstrate that the adversity experienced by neurotics has causes quite different to the random patterning of adversity experienced by non-neurotic persons. No such differences were however demonstrated. If the assumptions underlying this investigation are valid, then the results must be noted. The contingency of life events is an area needing further investigation. In any future study, it would be important to determine the role of the three aetiological factors in each subject’s events by detailed clinical interview so that the development, termination and social context of each event can be assessed individually for each subject. It may then be possible to differentiate various subgroups of neurotics and to determine the differing actiological factors in their life-events experience. REFERENCES

I DOHRENWEND B. S. and

Strrssjill Life 1~vrwt.s: Their hatrrrc mu/ John Wiley, New York (1974). GUNDERSON E. and RAHE R. H. (Eds.) ~Tijc .S~~ZKTurlcf ///ne.rs. C. <‘. Thomas, Springfield, III. (1974). BROWN G. W. Life events and psychiatric illness: some thoughts on methodology and causality. J. Psychoson?. Res. 16, 311 (1972). BROWN G. W. Meaning, measurement and stress of life events. In Strr.ssful Li/c EWI~J: Tkir Nature and EJyicts (Edited by DOHRE~VWENDB. S. and DOHRENWEND B. P.). John Wiley. New York (1974). BROWN G. W. Life events and the onset of depressive and schizophrenic conditions. In Li& Strcl.r\ andIllness (Edited by GUNDERSONE. and RAHE R. H.). C. C. Thomas, Springfield, Ill. (1974). MYERS J. K., LINDENTHALJ. J., PEPPERM. P. and OSTRANDER D. R. I-ife events and mental status: a longitudinal study. J. Hlth Sot. Behav. 13, 398 (1972). F~NTANA A. F., MARCUS J. L., NOEL B. and RAKUSIN J. M. Prehospitalization coping styI?< ol psychiatric patients: the goal directedness of life event?. J. New. Metrt. Di.s. 55, 31 I (1972). Eficts.

2. 3. 4.

5. 6. 7.

DOHRENWENLIB. P. (Eds.)

The cause

of life events

in neurosis

45

8. PAYKEL E. S., PRUSOFF B. A. and MYERS J. K. Suicide attempts and recent life events: a controlled comparison. Archs Gen. Psychiat. 32, 327 (1975). 9. TENNANT C. and ANDREWS G. A scale to measure the cause of life events. Amt. N.Z. J. Psychiatry 11, 163 (1977). IO. TENNAPUTC. and ANDREWS G. A scale to measure the stress of life events. Amt. N.Z. J. Psychiatry 10, 27 (1976). I I. ANDREWS G., SCXONELL M. and TENNANT C. The relation between physical, psychological and social morbidity in a suburban community. Am. J. Epidemiol. 105, 324 (1977). I?. GOLDBERG D. P. The Detection ofP.s,vchiatric Illrress by Questionnaire. Oxford University Press, London (1972). 13. GOLDBERG D. P., RICKELS K., DOWNING R. and HFSBACHER I’. A comparison of two psychiatric screening tests. Br. J. Psychiutr.y 129, 61 (1976). 14. TCNNANT C. The General Health Questionnaire: a valid index of psychological impairment in Australian populations. Med. J. Amt. 2, 392 (1977). I5 TENNANF CT.and AN~REWS G. The pathogenic quality of life-event stress in neurotic impairment. .Irchs G‘e/r. Psychiat. (in press). 16. ANDREW G., TENNANT C., HEWSON D. and VAILLANT G. Life-event stress, social support, coping style and risk of psychological impairment (manuscript in preparation). 17. KILOH L. G.. ANDREWS G., NEILSON M. and BIANCHI G. N. The relationship of the syndromes called endogenous and neurotic depression. Br. J. P.yychiutry 121, 183 (1972).