Stress and coping responses to a natural disaster in people with schizophrenia

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Abstract

Investigations of how individuals with schizophrenia differ from non-patients in their responses to stressful life events are subject to the criticism that any between-group differences might merely reflect differences in the types of stressful events that each group experiences. This report presents new analyses of data collected from schizophrenia patients (n = 96), bipolar disorder patients (n = 18), and healthy controls (n = 18) immediately after the Northridge Earthquake that struck Southern California in 1994, a natural experiment that confronted all groups with the same stressful event. Participants completed the Impact of Events Scale (IES; [Horowitz, M.J., Wilner, N., Alvarez, W., 1979. Impact of Events Scale. A measure of subjective stress. Psychosomatic Medicine 41, 209–218]) at 1 week and 5 weeks post-earthquake. At the 5-week follow-up, measures of coping, social support, and self-esteem were also completed. Both patient groups reported higher IES avoidance symptoms than controls immediately after the earthquake. The schizophrenia group also reported lower approach coping, self-esteem, and social support than controls, with the bipolar group reporting intermediate levels. Within the schizophrenia group, higher levels of avoidance coping predicted higher residual stress symptoms at follow-up. Results support the validity of prior reports of altered responses to stressful life events in schizophrenia and demonstrate the clinical relevance of individual differences in coping among affected individuals.

Introduction

The vulnerability-stress model of schizophrenia posits that symptom exacerbations result from a complex interplay between enduring psychobiological vulnerability, protective factors (e.g., coping competence, social support), and exposure to psychosocial stressors (Liberman, 1986, Nuechterlein et al., 1992). The validity of this model is supported by evidence that exacerbations of psychotic and depressive symptoms are preceded by increased levels of stressful life events (Ventura and Liberman, 2000) or exposure to high Expressed Emotion environments (Butzlaff and Hooley, 1998). It has also been proposed that schizophrenia is associated with heightened susceptibility to psychosocial stress (Walker and Diforio, 1997, Myin-Germeys et al., 2001, Myin-Germeys et al., 2005), though this proposal has not been uniformly supported (e.g., Jansen et al., 1998, Jansen et al., 2000, Horan and Blanchard, 2003, Horan et al., 2005a) and patients demonstrate considerable individual differences in their stress and coping responses (Hultman et al., 1997, Horan et al., 2005b).

Despite the substantial body of research linking stressful life events to the course of schizophrenia, a potentially important limitation of this entire line of research is that stressful events are idiosyncratic. That is, individuals with schizophrenia might experience qualitatively different events than individuals without schizophrenia. As a result, it can be argued that evaluations of how individuals react to and cope with life events are always compromised by uncertainty about the comparability of the events themselves. Life stressors rarely occur to an entire population at the same point in time. However, the occurrence of natural disasters provides a unique opportunity to explore the effects of a directly comparable type of stressor on people with and without schizophrenia and to evaluate individual differences in stress reactivity among people with this disorder.

In the current study, archival data were used to evaluate the stress and coping responses of schizophrenia patients and two comparison samples of bipolar patients and healthy controls following exposure to the Northridge Earthquake. On January 14, 1994, at 04:10 h, the Northridge, California earthquake, which registered a 6.9 magnitude, shook the greater Los Angeles metropolitan area. More than 1500 aftershocks were recorded during the 5 days following the main quake, including two that measured a 5.0 magnitude. The Earthquake left 61 people dead, 9000 injured, and 25,000 homeless, and was the Nation's most costly earthquake with widespread damage to the local infrastructure, homes, and businesses (Insurance, 1995, Noble, 1996).

Earthquakes and other disasters are known to precipitate psychiatric symptoms, including high rates of Post Traumatic Stress Disorder (PTSD) or associated symptoms (e.g., Chen et al., 2001, DeLisi et al., 2003). Factors found to increase risk for post-disaster psychiatric morbidity include higher levels of direct exposure or property damage, the presence of a prior psychiatric disorder, coping by avoidance, and lower social support (for reviews, see Katz et al., 2002, Norris et al., 2002). While the rate of PTSD is substantially elevated in individuals with severe mental illness (Mueser et al., 1998, Mueser et al., 2004), the handful of existing studies suggest that individuals with psychotic disorders do not deteriorate clinically and may actually improve in the wake exposure to disasters or emergency situations (see Katz et al., 2002 for a review). However, these studies typically did not include standardized assessments, were cross-sectional, included heterogeneous patient samples, were mostly uncontrolled, and did not directly assess PTSD-related symptoms.

Three issues concerning the stress and coping responses of individuals with schizophrenia to the Northridge Earthquake were examined. First, we evaluated whether schizophrenia patients reported higher stress-related symptoms than healthy controls at one- and five-weeks post-earthquake. The comparison sample of patients with bipolar disorder, which is also associated with sensitivity to psychosocial stressors (Hlastala et al., 2000, Cohen et al., 2004), enabled us to evaluate the diagnostic specificity of any differences in schizophrenia patients' responses. Second, in light of findings that individuals with schizophrenia demonstrate various manifestations of maladaptive coping (Horan and Blanchard, 2003, Ventura et al., 2002), we evaluated whether schizophrenia patients reported higher levels of avoidance coping and lower levels of approach coping than healthy controls. Bipolar patients were included in these analyses for exploratory purposes.

Finally, we sought to identify personal risk factors that render some schizophrenia patients more susceptible to severe and persistent stress responses than others. In addition to maladaptive coping strategies, schizophrenia patients often (though not always) experience diminished social support (Horan et al., 2006) and self-esteem (Ventura et al., 2004), which are associated with icreased susceptibility to stress (e.g., Skodol, 1998, Taylor and Aspinwall, 1996). Therefore, within the schizophrenia group, we evaluated whether maladaptive coping, lower social support, and lower self-esteem were associated with higher levels of persistent PTSD-related symptoms.

Section snippets

Subjects

The total sample of 121 participants was comprised of outpatients with schizophrenia (n = 85), outpatients with bipolar disorder (n = 18), and healthy, non-psychiatric controls (n = 18). Patients were recruited from research clinics at the UCLA Departments of Psychiatry and Psychology and the VA Greater Los Angeles Healthcare System, which cover the same catchment area. The schizophrenia and bipolar patients were taking a variety of psychiatric medications according to different research protocols or

Preliminary analyses

Correlational analyses indicated that neither sex nor ethnicity was significantly associated with any of the main study variables. Age was not significantly correlated with earthquake exposure, IES scores, or coping scores. However, in the total sample (n = 121) higher age significantly correlated with lower Social Support (r =  0.48, P < 0.001) and lower Self-Esteem (r =  0.36, P < 0.001). Therefore, age was entered as a covariate in between-group analyses of these two measures.

Consistent with previous

Discussion

Schizophrenia patients have often been found to differ from healthy controls in how they react to and cope with stressful events that occur in their daily lives. However, a criticism of this entire line of research is that it is impossible to experimentally control naturally occurring life stressors, and that differences in stress and coping may thus simply reflect differences in the nature of the stressful events that each group experiences. This potentially important methodological confound

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