Acontecimientos vitales estresantes y primer episodio psicótico
- Autores: Anna Butjosa Molines
- Directores de la Tesis: Susana Ochoa Güerre (dir. tes.), Juana Gómez Benito (codir. tes.)
- Lectura: En la Universitat de Barcelona ( España ) en 2017
- Idioma: español
- Tribunal Calificador de la Tesis: Montserrat Fuste Boadella (presid.), Georgina Guilera Ferré (secret.), Aida Farreny Sero (voc.)
- Materias:
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- Resumen
Nowadays, advances in affectlve and social neurosclence have shown how the exposure to environmenta1 factors has an impact on the structure and functioning of the brain being thus, active agents in the formation of an individual's leve! of vulnerability. There is an increasing interest in the influence of stress on many diseases includlng a first-episode psychosis (FEP). From the stress-vulnerability model (Zubin & Spring, 1977) to the current models of neural diathesis-stress (Pruessner et al., 2017), schizophrenia is conceptualised as an eplsodic disorder in which there is vulnerability and stress due to biological and/or environmental factors. This suggests that patients are likely predisposed to manifesting psychotlc episodes induced by the impact of preclpitating factors 1 such as stressful life events (SLEs).In FEP, the role of stressors, speclfically SLEs, as predisposing factors or adjuvants to the onset of the disease is relevant. These events are circumstances that occur in the lives of people with an identifiable beginning and end which have the potential to alter their current mental or physical status. However, there are very few studies on SLEs in patients with schizophrenia -and even fewer in patients with FEP-, thereby emphasising the need for such studies. SLEs can be treated as prodromal events, which together with other events, contribute to the appearance of later psychotic symptomatotogy.Indeed, it is !ikely that the diverslty of environmental factors associated with schizophrenia may be linked to an equal number of different underlying mechanisms. Severa! studies have eva!uated the role of SLEs, but most of the studies indude these events as trauma, what makes their research and evaluation more difficult and complicated.
Many studies have investigated the relationship between the presence of SLEs and age, seeking the stage of life with the highest number of SLEs and the type of SLEs that most frequently occur based on age. However1 the results indicate that other variables are involved in the increase of SLEs over time in addition to age.Moreover, the level of involvement of these SLEs and the probability of their occurrence and the development of psychopathologica! alterations vary according to the age and resources available to each subject. A life event occurring during an evolutionary stage will not have the same effect on an individual as one which takes place at a later stage of development, thereby making it necessary to evaluate the consequences that SLEs have based on the period of development of the individual. Adolescence and early adulthood are stages with great changes at family, social and biological level. Thus, the changing nature of thls evolutionary period is important, with maturational deve/opment precesses playing an important role.In addition to the stress vulnerability model, the complex aetiology and heterogeneous clinical manifestations of psychosis make it necessary to focus on the cllnical staging model and en an early intervention. This prometes rapid access to care and to a comprehensive treatment in the initial stages of the disorder1 and allows analysis as well ef the role of the psycho!ogical mechanisms involved in the real-life expression of psychotic symptoms in indlviduals with FEP. To achieve appropriate and effective early lntervention in psychotic disorders, further studies are needed to identify early markers of psychotic i11ness and characterise the early phases of psychotic disorders.
This thesls was aimed at achieving adequate and effective early intervention in psychotic disorders since: i) in general, few studies have specifically eva!uated SLEs; ii) no studies have analysed the age of onset of FEP in relation to SLEs; iii) no studies have been found about gender differences, family history and psychotic symptomatology in relation to SLEs; and iv) no instruments are available to assess SLEs along the life cycle. The main objective of this thesis was to evaluate the re!ationship between SLEs and the development of FEP. This objective was devetoped under three specific objectives: 1) to systematically review the Hterature available on SLEs and FEP 21 to evaluate the imnact of SLEs and the influence of sociodemographic and clinical variables on the appearance of FEP, and 3) to validate an instrument to measure SLEs in FEP and in a healthy population. Each of these objectives was associated wlth a study. The first objective was analysed in Study 1.
This study reviews the !iterature on SLEs and their influence on the appearance of FEP. For the review we selected the leading studies on SLEs including key aspects such as adolescence 1 coping, resil!ence and ethnic differences. Study 1 provides a review of the literature in reference to SLEs with respect to: i) the stress-vulnerability model, ii) SLEs in patlents with FEP, iii) SLEs, FEP and adolescence, iv) coping and resilience, and v) ethnic differences. A search was conducted between 1980 and 2013 using Psyc!NFO, MEDLINE and PSICODOC using the following terms: Stressful life events, adolescence, coping, resilience, schizophrenia, stress, first psychotic episode, and vulnerability. A total of 289 studies were found, 59 of which were selected for review. Overall1 the review highlights the importance of certain psychosocial factors which may cause a significant change in subjects' lives and, consequently, requlre an adaptation response. The central nucleus is the adaptation to the environment and, consequently, the production of dynamic changes in the individual. An example is the effect of SLEs, which is considered an environmental factor that produce conflict, challenge and change in subjects.Integrated assessment of SLEs together with other individual and contextual variables, constitute an approach for the ear!y detection of FEP as a means of prevention. The results show the need for a multiple comprehensive approach because of the different factors involved ln the nexus with which FEP is made up. The second objective was evaluated in Study 2.It analysed the incidence of SLEs and the impact of sociodemographic (gender and age) and clinical variables (age of onset of FEP, psychotic symptoms and family history) on the appearance of FEP. We used the Psychiatric Epidemiology ResearchInterview Life Events Scale which assessed the year before the onset of FEP. The results of Study 2 showed that significant differences according to gender were only found far the category of legal affairs in adolescent males. Age at onset presented a signlficant negative corre!ation with the categories of academic and social activities. By contrast, a positive correlatlon was found with work and children. A significant relationship was seen between paterna! family history and social activities and between maternal family history and academic and love and marriage. Final!y, an inverse relationship was observed between negative symptoms and the categories of children and finance. Depressive symptoms were significantly correlated with the category of academic.
Overall this paper showed the following results: i) the high incidence of SLEs in FEP, ii) there are more SLEs in subjects with a maternal/ paternal family history of mental disorders, and iii) the age at onset and psychotic symptoms were associated with the presence of SLEs. The results showed the importance of SLEs during adolescence and suggested a crear need to develop preventive actions to manage the accumulation of psychosocial stress. Studies 1 and 2, demonstrate the need to assess SLEs along life and consider the analysis of the re!evant characteristics of SLEs such as age of the subject at the time of FEP and the levels of stress or of emotional impact. The third objective was evaluated in Study 3. This was a psychometric study focused on the comparison of the development and validation of the 'Questionnaire of Stressful Ufe Events' (QSLE)' in patients with FEP with respect to a healthy population. The studies available on SLEs show the need to identify the most important SLEs and evaluate the different properties of SLEs in different types of samples (Abad et al., 2000; Lemos et al., 2002).In this thesis, in addition to a FEP sample, a sample of healthy controls was included in arder to assess the most influential SLEs. The subjective burden of stress was also included in each item of SLEs since stress can affect their perception. This led to the development and validation of the QSLE that could be helpful to identify which SLEs should be evaluated before a FEP, and to assess SLEs as well as other specific variables along life such as age at the time of the SLEs, and qualitatively, the level of stress or the emotional impact.
Study 3 involved the development and validation of the questionnaire on SLEs (QSLE), which described speciflc items of childhood, adotescence, and adulthood focused on the presence of SLEs, emotional impact (stressfulness), and the age at which the event occurred in patients with FEP and healthy controls. An item pool was generated and content validity was eva1uated. We then assessed the evidence of the re!iability and validity of the QSLE: i) itemlevel analyses, il) intra-rater reliability, and iii) convergent and discriminant validity. Lastly, sensitivity and speclficity analyses were peliormed. The questionnaire showed good psychometric properties. The seores were re!iable and valid and, thereby this is a useful instrument for the measurement and detection of SLEs that occur during the life cycle in patients with FEP as well as healthy subjects. The findings of study 3 suggest that the QSLE allows the investigation of childhood, adolescent, and adu!t life events by measuring stress and the age at the time of the SLEs on a continuous sea le, being optima! for psychosis studies. The QSLE also assessed the presence and levels of stress thereby providing additional knowledge of the impact of SLEs on psychosis. The data obtained in this thesis provide more in depth knowledge regarding SLEs and their evaluation and detection as well as the relationship of these events with clinical variables and symptoms in a sample of patients with FEP and healthy controls. This doctoral thesis has focused on the study of SLEs and psychosis. The objective of identifying SLEs across the stress-vulnerability model psychosis phenotype continuum may provide insights into the aetiology of this disorder and mav lead to the develonment of strateaies far its orevention and treatment.
Furthermore, different studies have suggested that SLEs play an important role in the precipitation and relapse of psychiatric disorders; however, the relationship is not so simple. There are other vulnerabilities that may influence the precipitatlon of the disorder, such as differences in the social support system, skills, attitudes, beliefs and personality characteristics (Cohen & Hamrick, 2003; Fumero, Santamaría, & Navarrete, 2009; Pandurangi & Kapur, 1980). These factors may make sorne people relatively immune to disease-induced stress and others relatively susceptible, leading to the development of a FEP. A large number of causative factors as well as the wide developmental time period and the presence of numerous moderating resilience factors seem to be consistent with the psychopathological space between healthy individua! differences in schizotypal personality traits and severe psychotic psychopathology.In addition, it has been unvelled that there are dynamic developmental changes in the individual's position along this hypothetic continuum of risk and resilience to psychosis. There is evidence that SLEs interact with FEP, and consequently, the determination of SLEs might be particularly useful to develop strategies to prevent the development of FEP. There is a need to implement strategies that guarantee the identification of psychosis and treatment in the earliest phase, as well as to achieve early control of the suffering that the disease produces to the patient and the key figures within their environment. We provide further corroboration that rather than being a correlate of frank psychosis, the variability of SLEs may play an important role in FEP populations and this is of great relevance to the practice of professionals dedicated to detecting 1 caring far, and treating people with this disease. The work presented in this thesis is framed within the stress-vulnerability model and the ctinical staging model, which considers the phenotypic continuum reflecting a shared interactive set of diathesis, psychosocial and sociocultural factors. Currently, few studies have evaluated SLEs in these sample types and there is a need to obtaln more in depth information on the influence of SLEs in these populations in which aenetics and stress olav a relevant role.
