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Diathesis Stress Theory - Schizophrenic
Several features of the Jansen et al study limit its value as a test of the hypothesis under consideration. Firstly, the stressor was not designed to be social-evaluative. In the meta-analysis of Dickerson and Kemeny, elements of an experiment that indicated a social-evaluative stressor were that the threat involved: (a) permanent recording of the performance, (b) presence of an evaluative audience during the task (at least one other person present besides the experimenter), and (c) presence of a negative social comparison, such as real or potential outperformance by another. The only social-evaluative elements in the study of Jansen and colleagues were permanent recording (via videotape) and a suggested, although not actual, evaluative audience. Because no control task was used, increased heart rates cannot be attributed to the spurious evaluative audience. This experiment did not meet any of the criteria of Dickerson and Kemeny for uncontrollability, and no subjective reports of the stressfulness of the task situation were elicited. Indeed, the blunting of the cortisol response in schizophrenia patients could be interpreted as reflecting a disorder-related cognitive dysfunction, such as misinterpretation of the situation or the stress stimulus. A further issue is that the patients had been receiving stable doses of neuroleptics for at least 3 months, suggesting that the confounding effects of medication on cortisol reactivity cannot be ruled out. Indeed, although no comparison of patients' and controls' basal cortisol levels was made, graphical representations of these data suggest no difference between the groups, in contrast to the pattern that would be expected in unmedicated samples. The fact that none of the participants were first-episode patients suggests a further potential confound resulting from previous HPA-axis hyperactivity (see above). We therefore conclude that there is, as yet, no direct evidence that it is specifically stressors perceived as presenting an uncontrollable and social-evaluative threat to the self that are important for triggering a preexisting vulnerability to schizophrenia. We return later to what a suitable experimental test of our hypothesis would involve.
It is a widespread myth that choice of method mirrors the intention to die. However, studies of suicide after suicide attempt have shown conflicting results concerning the predictive value of the dangerousness of the attempt with regard to later suicide. It is a consistent finding in studies worldwide that women are more likely to die from self-poisoning, while men more often die from more fatal methods such as shooting, car exhaust, and hanging. Denning et al. [Denning et al., 2000] used data from a psychological autopsy study (n=141) and showed that there was a strong association between gender and choice of method (violent versus non-violent) even after adjusting for intention to die, presence of psychiatric disorder, substance abuse and socio-demographic variables. However, it can be hypothesized that a high number of women with low suicidal intent survived the suicidal act and were therefore not included in the above-mentioned study. The optimal design for studying the question of suicidal intention and lethality of the method is a cross-sectional study involving a consecutive sample of persons committing fatal or non-fatal suicidal acts. To my knowledge no such study has been carried out.
Claims of the Diathesis Stress Model of Schizophrenia
Our hypothesis about the specific psychological conditions that interact with a preexisting diathesis to trigger schizophrenic episodes lends itself to a range of possible empirical tests. We begin by noting that judging situations as involving an uncontrollable, social-evaluative threat to the self is a subjective process, which is likely to be affected by the disorder itself. Specifically, a situation that a normal individual finds innocuous may very possibly be interpreted as uncontrollable and/or social-evaluative by an affected individual. Patients with delusions of reference, eg, are particularly likely to perceive such features in neutral events (eg, a glance from the mailman) or even positive events (being smiled at by the mailman). Attentional biases may further complicate this picture., Thus, laboratory paradigms designed to introduce uncontrollable or social-evaluative situations may not have the intended effects on participants with schizophrenia. One possible solution might be to ask individuals to give subjective ratings of situations on these dimensions. The methodological issues around achieving such ratings would of course need careful consideration.
The first potential test of our hypothesis would be to examine cortisol changes in first-episode, drug-free patients with schizophrenia, in response to both naturalistic and laboratory stressors that they have subjectively rated as presenting uncontrollable, social-evaluative threats to the self, and which also meet all the criteria of Dickerson and Kemeny for such a stressor. Our hypothesis would predict that cortisol responses should be elevated in patients in such situations. In contrast, stressors not rated as presenting uncontrollable, social-evaluative threats should not cause significant cortisol responses. Although the ethical implications of such investigations would need to be considered carefully, any such stress-related cortisol increases should further relate to the exacerbation of specific symptoms of schizophrenia (eg, auditory verbal hallucinations, persecutory delusions) in such situations.
Bipolar Causes: Diathesis-Stress Hypothesis - Bipolar …
The model of Walker and Diforio aims to explain how particular neurobiological consequences of stress interact with a biological diathesis to shape the expression of psychiatric symptoms. It is not concerned specifically to explore the psychological conditions under which such a stress response might arise. One obstacle, therefore, to applying this model in explaining psychosocial influences on the genesis and maintenance of schizophrenic symptoms is the assumption that psychosocial stressors, a notoriously subjective concept, form a homogeneous category with similar physiological effects. For example, Walker and Diforio(p669) claim that “cortisol release is linked with acute exposure to stressors across the life span,” without exploring how such stressors might differ in their ability to alter cortisol levels.
With these caveats in mind, the generalization of the findings of Dickerson and Kemeny to real-life settings and their integration with the neural diathesis–stress model of Walker and Diforio lead to a number of testable hypotheses. Specifically, we hypothesize that it is perceiving situations to involve social-evaluative threats combined with uncontrollable outcomes that trigger schizophrenic symptoms (where a vulnerability exists) or worsen existing symptoms. Furthermore (although leading to weaker effects), perceiving situations to have either of these elements, ie, to be social-evaluative or to involve uncontrollable threats to important goals (including the goal of maintaining the social self), will also be able to either trigger schizophrenic symptoms (where a vulnerability exists) or worsen existing symptoms. Conversely, stressors not of these types would be predicted not to trigger or exacerbate the symptoms of schizophrenia. We now examine whether this hypothesis finds support from existing research findings.
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Diathesis stress model and schizophrenia
It has been argued that the neural diathesis–stress model of schizophrenia can usefully be expanded to account for the heterogeneity of effects of psychological stressors. Evidence has been presented that it is specifically the situations perceived as social-evaluative and those involving uncontrollable threats to important goals that raise cortisol levels in healthy individuals. We have hypothesized that this pattern will be reflected in first-episode, drug-free patients with schizophrenia and will be responsible for both triggering and exacerbating the symptoms of schizophrenia. However, as noted above, it is yet to be demonstrated that such cortisol reactivity patterns are similar between healthy individuals and schizophrenia patients. If supported, such a hypothesis leads to clear implications for treatment and management of schizophrenia. In considering future research, it is clear that more research is needed into the relation of stress to the etiology and course of schizophrenia, and that a multidimensional model of stress will be valuable in this effort.
A Diathesis-Stress Model of Personality Disorders - …
Another potential test of our hypothesis could be implemented by the study of monozygotic twins discordant for schizophrenia. Assuming an equivalent biological diathesis in each case, we would hypothesize that the triggering of the diathesis in the twin with schizophrenia would result in part from a greater lifetime exposure to perceived uncontrollable and social-evaluative situations that would be reflected in higher subjective ratings on these variables. Potential confounds in assessing such exposure would include autobiographical memory deficits associated with schizophrenia and the attentional deficits and overvalued ideas discussed above. An alternative approach would be to identify an at-risk population such as young adults with at least 2 first- or second-degree relatives with schizophrenia. We would hypothesize that subjective ratings of exposure to events perceived as social-evaluative or those involving uncontrollable threats to important goals, and particularly ratings of exposure to combinations of both, would prospectively predict the probability of developing schizophrenia. However, the temporally limited nature of cortisol reactivity means that one would expect the high-risk group to show an elevated risk of onset for a limited period, rather than a raised lifetime risk of schizophrenia.
The differential susceptibility hypothesis is a recent theory that ..
The purpose of a model is to provide us with a theoretical construct upon which we can place our theories about ethiology, pathogenesis and expression [Silverman, 1996]. The diathesis-stress model can be used as a framework for understanding suicidal impulses and suicidal behaviour. The threshold model for suicidal behaviour has been suggested by Blumenhal and Kupfer [Blumenthal and Kupfer, 1988]. This model subdivides factors into predisposing factors, risk factors, protective factors and precipitating factors. The model can be seen as an elaboration of the diathesis-stress model. To develop preventive interventions requires theoretical considerations and empirical knowledge about ethiology and pathogenesis and empirical data concerning risk factors, predisposing factors, protective and precipitating factors, and effectiveness of preventive measures.
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