Relapse in young paranoid schizophrenic patients: a prospective study of stressful life events, P300 measures, and coping

Abstract

T he role of independent life events in schizophrenic relapses has been well documented in both retrospective (1, 2) and prospective (3, 4) studies. However, what deserves further consideration is that at least 50% of the instances of schizophrenic relapse occur without any increase in major life events in the preceding 1-month period (4, 5), suggesting that these patients may experience acute accentuations of vulnerability to relapse as a result of natural oscillation in their biological systems (4). To our knowledge, to date there have been no investigations relating the cognitive characteristics of schizophrenic subjects to the level of stress at the time of relapse, and the aim of the present study was to start to fill this gap.Schizophrenic vulnerability (comprising, for example, certain cognitive dysfunctions and specific coping limitations) may be associated with sensitivity to socioenvironmental stress factors that lift the individual's susceptibility over the threshold beyond which an exacerbation of psychotic symptoms or a relapse can be expected (6, 7).One serious difficulty in carrying out this kind of study relates to the process of assessing and determining the degree of reliability of the recollection of life events during the course of the disease. To avoid the common biases that can occur in this kind of research, a series of measures were adopted: prospective research with follow-up analysis, schizophrenic subtyping (in order to avoid producing results that cannot be extended to an entire schizophrenic subpopulation), the use of appropriate criteria to define relapse, and the use of appropriate instruments for the assessment of stressful life events, such as Brown and Harris's Life Events and Difficulty Schedule (8), which was conducted by a trained expert.In their ongoing longitudinal study of developmental processes in schizophrenia, Nuechterlein et al. (5,9) focused on several information-processing neuropsychological and neurophysiological indexes ("stable vulnerability indicators"), but they did not consider each subject's coping strategies and the level of subjective experiences, nor did they consider the P300 event-related potential, which is one of the most reliable indexes of information-processing dysfunction (10-12).Moreover, lower rates of relapse (13,14) have been associated with a small P300 amplitude in schizophrenic patients.We may hypothesize that this susceptibility to stress

Are adult stressful life events associated with psychotic relapse? A systematic review of 23 studies

“…Results from included studies are summarized in Table 1. Eighteen studies (n = 1513) reported a significant association between stressful life events and subsequent relapse of psychosis (Aronson & Shukla, 1987;Birley & Brown, 1970;Castine et al, 1998;Chabungbam, Avasthi, & Sharan, 2007;Christensen et al, 2003;Das, Kulhara, & Verma, 1997;Ellicott, Hammen, Gitlin, Brown, & Jamison, 1990;Hirsch et al, 1996;Hui et al, 2016;Hultman, Wieselgren, & Öhman, 1997;Hunt, Bruce-Jones, & Silverstone, 1992;Leff, Kuipers, Berkowitz, Vaughn, & Sturgeon, 1983;Nuechterlein et al, 1992;Pallanti, Quercioli, & Pazzagli, 1997;Sam, Nisha, & Varghese, 2019;Simhandl, Radua, König, & Amann, 2015;Subramanian, Sarkar, Kattimani, Philip Rajkumar, & Penchilaiya, 2017;Ventura, Nuechterlein, Lukoff, & Hardesty, 1989), whereas five studies (n = 531) found a non-significant association between stressful life events and subsequent relapse of psychosis (Al Khani, Bebbington, Watson, & House, 1986; Dols Significantly more SLEs in 3 months prior to relapse in relapsed than non-relapsed (mean number of events = 0.85 v. 0.51), ( p < 0.001). The number of SLEs also significantly higher in 1 month prior to relapse in relapse group v. non-relapsed ( p = 0.02).…”

“…Thirteen studies explicitly made a distinction between the dependent and independent life events, with 10 of these studies finding a significant association between independent life events and psychotic relapse (Aronson & Shukla, 1987;Birley & Brown, 1970;Christensen et al, 2003;Hirsch et al, 1996;Hultman et al, 1997;Hunt et al, 1992;Leff et al, 1983;Nuechterlein et al, 1992;Pallanti et al, 1997;Ventura et al, 1989), indicating that the observed association is not restricted to life events occurring in the context of illness.…”

“…Of the 19 studies defining relapse as a return of psychotic symptoms, 14 studies (74%) found a significant association between stressful life events and relapse (Aronson & Shukla, 1987;Castine et al, 1998;Chabungbam et al, 2007;Christensen et al, 2003;Das et al, 1997;Ellicott et al, 1990;Hirsch et al, 1996;Hui et al, 2016;Hunt et al, 1992;Leff et al, 1983;Nuechterlein et al, 1992;Pallanti et al, 1997;Subramanian et al, 2017;Ventura et al, 1989), whereas five studies did not find a signficant association (Al Khani, Bebbington, Watson, & House, 1986;Dols et al 2018;Draman at al., 2005;Malla, Cortese, Shaw, & Ginsberg, 1990;McPherson et al, 1993). The one study defining relapse as readmission or a return of symptoms found a positive association between stressful life events and relapse (Simhandl et al, 2015).…”

“…Clinical diagnosis varied between studies. Fourteen studies included participants with a diagnosis of schizophrenia, psychosis or schizoaffective psychosis, of these, 11 studies (79%) found a significant association between stressful life events and relapse (Birley & Brown, 1970;Castine et al, 1998;Chabungbam et al, 2007;Das et al, 1997;Dols et al, 2018;Hirsch et al, 1996;Hui et al, 2016;Hultman et al, 1997;Leff et al, 1983;Nuechterlein et al, 1992;Pallanti et al, 1997;Ventura et al, 1989). Eleven studies included participants with bipolar I or bipolar II disorder, of these, nine found a significant association between stressful life events and relapse (Aronson & Shukla, 1987;Christensen et al, 2003;Ellicott et al, 1990;Hunt et al, 1992;Sam et al, 2019;Simhandl et al, 2015;Subramanian et al, 2017).…”

Coping in residual schizophrenia

“…They may avoid facing stressors rather than considering possible courses of action or attempting to solve problem 1 9 . These coping strategies have been considered ‘ineffectual’ and maladaptive as these correlate with greater distress 10 , lesser hope, lower self-esteem and more depressive symptoms 7 , increased symptom severity 11 or relapse 12 and poorer quality of life (QOL) 13 . It has also been suggested that these individuals have a restricted repertoire of coping strategies that they employ when under stress 7 .…”