Abstract
The goal of this book, according to its editor and long-term stress researcher, Bruce Dohrenwend, is to help reverse the excessive swing toward an ethos of biological, as against environmental, causes of psychiatric disorders. The book is meant to provide upto-date scientific evidence that psychosocial factors are at least as important as biological ones. Thus the book supports nurture in the nature-nurture debate.
The book is worth reading for those who want state of the art knowledge of where the stress causation of mental illness stands today. It can also serve as a reference book for those interested in effects of particular types of stressors, and the role of stressors in particular disorders.
Section I starts the environmental argument from a safe premise. A number of chapters indicate unequivocal evidence that extreme stressors such as genocides and combat lead to short- and long-term posttraumatic stress disorder (PTSD). The premise is safe because the disorder PTSD is by definition a result of extreme environmental stressors.
But what is more intriguing is that major depression frequently coexists with PTSD. Indeed, a great variety of disorders and dysfunctions coexist with PTSD, PTSD really covering only a small section of disorders of stress. Further, as meaninglessness of life underlies much unhappiness, and refinding meaning is essential to the healing process, enquiry at the DSM-IV diagnostic disorder level may not capture the human breadth and depth of environmental disruption. Unfortunately, the book does not follow up these findings, being simply intent to prove that a circumscribed number of disorders is influenced by environmental factors.
Sections II and III are important for psychiatrists because they indicate that the common ‘ordinary’ stresses of life also lead to psychopathology. Thus bereavement, divorce, unemployment, low socioeconomic status and unfavoured ethnic status each individually contribute to excess mortality and morbidity. With regard to particular psychiatric disorders, these ‘ordinary’ stressors contribute to depressive, anxiety and phobic disorders in women, and alcoholism, and antisocial personality disorders in men. No specific stressors were linked with specific illnesses, except threat to life with PTSD, and life losses with depression.
The authors are careful to distinguish the stressors to be primary and not the result of the disorders, though it is noted that the reverse may be true for schizophrenia. In parentheses, it may be noted that the results are very similar to the first generation of stress and illness research half a century ago, with the exception of PTSD which did not exist then.
Section IV makes the point that moderating and amplifying (strength and vulnerability) factors influence outcomes following stressful situations. Such factors include social support, coping mechanisms, personality factors such as self-esteem and internal locus of control. Unfortunately, these factors are still poorly defined. For instance, it was found that perception of social support was more important than actual support, and some support could actually be experienced as negative.
Section V highlights some conceptual questions. For instance, very early stressors in life such as unsatisfactory attachment can lead to misattunements and physiological skewings which, in turn, lead to long-term vulnerabilities. This may help to explain findings in an earlier chapter where it was shown that abused and neglected children tended to develop in later life a great variety of psychopathology and psychosocial dysfunctions. The point is, that even if long-standing and intractable, the later conditions should not be simply attributed to genetic factors.
Yet one needs to be similarly careful that genetic factors are not ignored. For instance, it is noted that temperament may affect later sensation seeking and placing oneself in relatively dangerous situations.
Indeed, it may be retrograde to dichotomise the nature-nurture controversy. Genetic factors, after all, prepare for environmental conditions which themselves evoke or mould genetic potential.
Section VI summarises and integrates the book. It indicates the need for a multidimensional dynamic view of the stress-illness perspective. For instance, post-stress consequences depend on complex biological, psychological and social, antecedent, stress-related and ongoing factors. And we still need a taxonomy of stressors and a theory which connects types of stressors, appraisals, coping and adaptive and maladaptive responses with subsequent symptoms and disorders.
One criticism of the book is its dryness. In an effort to prove its point it sets very circumscribed goals and uses only scientifically acceptable, statistical case-control methodology. As Dohrenwend admits, this approach misses out on important dimensions of events, their richness and complexity, which need to be supplemented by intensive case studies.
A second criticism is that, because the authors were drawn from a specific conference, some sections of relevant literature were not incorporated. For instance, physiological responses and their potential consequences for increased physical illnesses and mortality rates were ignored. Similarly, the range of symptoms and diagnoses in psychiatric pathology was too narrow. For instance, somatisation and adjustment disorders were not given due attention. Thus, though the book is an improvement in scientific methodology on early stress research, in other ways it is conceptually behind it.
Finally, I would like to draw attention to a delightful chapter by Leighton which gives a meta-perspective on the question of stress and psychopathology. He points out that beliefs and research grants are influenced by the zeitgeist of the era. The first wave of acceptance that stress led to illnesses peaked after the Depression and World War II, when their widespread effects could not be ignored. In the post-war euphoria it was expected that the obvious ills which caused so much misery would be quickly corrected. Disillusionment followed, until a new wave of euphoria spawned by discovery of some psychotropic drugs led to an expectation of biochemical erasure of misery. Currently, the importance of psychosocial stressors is recognised again.
What is still required is a meta-theory which incorporates in a common sense way biological, psychological and social stressors and consequences, from molecular to cultural perspectives.