VOL.

Comprehensive Psychiatry Official Journal o f .the A m e r i c a n ,Psychopatho log ica l Assoc ia t ion

14, NO. 3 M A Y / J U N E 1973

T h e I o w a 500: P r e c i p i t a t i n g F a c t o r s i n S c h i z o p h r e n i a a n d P r i m a r y A f f e c t i v e D i s o r d e r

J o h n Clancy. R a y m o n d Crowe. G e o r g e W i n o k u r . and J a m e s M o r r i s o n

W E have previous ly descr ibed a s a m p l e o f 525 hospi ta l ized pat ients suffering from pr imary affect ive d isorder of schizophrenia . ~ T h e s a m p l e was se-

l ec ted from hospital records 2 5 - 3 5 years ago and d iagnosed on the bas is of re- search criteria descr ibed by F e i g h n e r e t a l / W e are o f the opinion that we have i so lated h o m o g e n e o u s d iagnost ic groups for s tudy. F u r t h e r m o r e , in respect to the quest ion of d iagnost ic validity we found that in 200 sch izophren ic pat ients d iagnosed according to the criteria w e used there w a s chart a g r e e m e n t in 95%, and in 325 af fect ive d i sorders there w a s 93% a g r e e m e n t with the original chart d iagnos is based on the revised c lass i f icat ion adopted by the A m e r i c a n Psych ia tr i c Assoc ia t ion o f 1934.:~

This paper dea l s with precipi tat ing fac tors in respect to a n u m b e r o f charac - ter i s t ics o f pat ients d iagnosed as pr imary af fect ive d isorder or schizophrenia . It is not our intention to enter into a d i scuss ion o f the relat ive mer i t s o f c lass i f icat ion o f psychiatr ic d i s e a s e s based on psychot i c or neurot ic concept s , e n d o g e n o u s or e x o g e n o u s types or quant i ta t ive or qual i tat ive d~fferences in s y m p t o m a t o l o g y . T h e s e controvers i e s have been d i s c u s s e d in detai l by o thers . R a t h e r , it is our a im to report the p r e s e n c e or a b s e n c e of prec ipi tat ing factors on the basis of in- format ion obta ined from the patients" records o f this research sample , and to at- t empt to relate these factors to o ther var iab les m e a s u r e d .

M ETH OD

Three of the investigators examined the case records of all patients consecutively admitted to the Iowa State Psychopathic Hospital starting in the year 1935. Records were included in the study sample if they met the research criteria for either primary affective disorder or schizophrenia, z Primary affeetive disorder can be subdivided into two types. Unipolar affective disorder refers to patients who have had only depressions. Bipolar refers to persons with manic depressive illness (all

Front the Department o f Ps;'chiatr;', College o f lttedicine anti Psj"chopathie Hospital. University o f Iowa, Iowa City, Iowa 52240

Supported in part b)" USPHS Grants 31H-05911, zld ll-11396 and MH-12631. John Clancy, M.D.: Professor of Psychiatr)'. Colh'ge o f h4edicine and Psychopathic Hospital.

University o f lowa, Iowa Cio', Iowa; Raymond Crowe , M.D.: Instructor in Psychiatry. College o f Medicine and Psychopathic Hospital. Universi O" o f Iowa, Iowa Cio', Iowa; George Winokur, M.D. : Professor and Head o f the Department of Psrchiatry, Colh,ge of Medicine and P.Lrehopathic Hos- pital. University o f Iowa. Iowa City. lowa," James Morrison, M.D. : ,4.,Mstant Professor o f Psychiatry, College o f Jledieine and Psychopathic ttospital. UniverMty of Iowa. Iowa City. Iowa.

© 1973 b), Grune dk Stratton, Inc.

Comprehensive Psychiatry, VoL 14. No. :3 (May/June). 1973 197

1 9 8 CLANCY ET A L

had at least one episode o.f mania). A sufficient number of bipolar affective disorders (100) and unipolar affective d isorders (225) had been compiled by the middle of 1940. Between 1935 through 1944 an insufficient number of schizophrenics had been collected so the desired number of 200 was

filled out from admissions in the year 1934. The records were of an unusually consis tent high standard. Th'e medical records contained a com-

plete psychiatric history, a detailed family and past medical history, a mental status, diagnostic for- mulation, report of laboratory studies and consultations, progress and t rea tment notes, discharge and report on final disposition of patient. The .records were supplemented by complete social histories gathered by hospital social workers, with part icular emphasis on cha rac t e r and diseaffes of,ft:mily members. In addition repor ts from o the r hospitals and physicians were nearly always included in the pa t i en r s record. A unique feature of the patient 's examination was a rePort of the stalling conference relative to each patient 's diagnosis and t rea tment program. The comments , .debate , and arguments of professors, attending physicians, and residents were all taken down in shorthand by a s tenographer and later typed and included in the patient 's permanent record. These reports reflected high quality and sophistication of staff.discussions and were very productive of data for study purposes.

In o rde r for a factor or.an event to be considered as a precipitant, it was necessary ( ! ) to have evi- dence from the patient 's chart that the patient had stated, or a relative or attending physician had ob- tained information from the patient tha t the event was indeed considered stressful. (2) If such in- formation was not present in the chart , then the investigator was permit ted to judge whether the fac- tors or events which preceded the onset of illness were things "likely'" to be considered stressful. (3) In addition the stress had to be severe. (4) Dating an event to onset ofi l lness will almost always in- volve a degree of judgment . The possibilities of e r ro r are probably reduced when the events are of re- cent origin and information is available from multiple sources. ' We chose a time limit of three months prior to onset of illness. Only in those cases where there was definite information in the record to exceed this la t ter limit were such events included. It should also be remembered that in accordance with the diagnostic criteria employed ~ mania had to be present for two weeks, depression for one month and schizophrenia for six months before being admit ted to the study.

Precipitating factors were categorized as psychological, physical, social, combinations of the afore- mentioned categories, postpar tum and menopausal. The determinat ion into which o f the first three categories a given factor or event should be placed was left to the investigator. The number o f factors considered to be a precipitant a re practically endless but tend to fall into broad groupings, Physical factors include t rauma, surgery, receig'ing or stopping medications with psychoactive properties, prolonged work. fatigue, particularly under poor living or climatic conditions, etc. Psychological fac- tors included those items associated with personal loss or d,:sappointment, such as bereavement , de- par ture of family member , divorce. Social factors considered to be precipitants included advancing age, ret i rement, failing abilities, demotion in status, diminished capacity to engage in previously en- joyable recreation, poverty, etc. Some of these had more than one dimension and therefore ~'ere recorded in a combined category. Sepa ra t e class status was also given to the pos tpar tum and menopausal state.

R E SO LTS

T h e p r e c i p i t a t i n g e v e n t s f o r t h e t h r e e d i a g n o s t i c g r o u p s a r e s h o w n in T a b l e 1.

O f t h e u n i p o l a r a f f e c t i v e d i s o r d e r s , 3 9 % w e r e f o u n d t o h a v e a p r e c i p i t a t i n g e v e n t .

T h e b i p o l a r a f f e c t i v e d i s o r d e r s w e r e f o u n d t o h a v e a p r e c i p i t a n t in 2 7 % o f c a s e s .

T h i s d i f f e r e n c e is s i g n i f i c a n t a t t h e .05 l e v e l ( X " -- 3 . 9 2 ) . O n l y 1 1 % o f l h e

s c h i z o p h r e n i c s h a d a p r e c i p i t a t i n g f a c t o r , a s i g n i f i c a n t d i f f e r e n c e f r o m t h e b i p o l a r

a f f e c t i v e d i s o r d e r s (/9 < .01 , X'-" = 1 1 .34) .

T h e p r e c i p i t a t i n g f a ~ : t o r s w e r e a r r a n g e d i n t o s ix c l a s s e s : p s y c h o l o g i c a l ,

p h y s i c a l , s o c i a l , c o m b i n a t i o n s o f t h e s e , p o s t p a r t u m , a n d m e n o p a u s a l . E a c h o f

t h e s e c l a s s e s s h o w e d s i g n i f i c a n t d i f f e r e n c e s a c r o s s t h e t h r e e d i a g n o s t i c g r o u p s

w i t h t h e e x c e p t i o n o r p o s t p a r t u m . T h e t r e n d is f o r m o r e p r e c i p i t a t i n g f a c t o r s t o

b e f o u n d a m o n g t h e a f f e c t i v e d i s o r d e r s , w i t h u n i p o l a r t e n d i n g t o h a v e m o r e t h a n

b i p o l a r i l l n e s s . P s y c h o l o g i c a l f a c t o r s w e r e t h e m o s t f r e q u e n t l y f o u n d p r e c i p i -

S C H I Z O P H R E N I A A N D ,PR IMARY AFFECTIVE D I S O R D E R 1 9 9

Tab le I

Unipolar AD Bipolar AD Schizophrenia N = 225 /V = 100 N = 2 0 0

(%) (%) {%)

A n y p r e c i p i t a n t 3 9 2 7 11 p < .OO1 P s y c h o l o g i c a l 17 9 4 p < ,001

Phys ica l 5 12 3 p < .O1 Soc ia l 5 0 1 p < :01 Psych ia t r i c p l u s

phys i ca l p lus soc ia l 3 0 0 p < .01 P o s t p a r t u m 3 . 5 6 2 . 5 N.S. M e n o p a u s a l 5 0 0 . 5 p < .01

" A l l p r o b a b i l i t i e s a re X 2.

t a t ing events . T h e one excep t ion was b i p o l a r i l lness w h e r e phys i ca l f a c t o r s s l igh t ly exceeded psycho log ica l .

N e x t we e x a m i n e d the d a t a to d e t e r m i n e w h e t h e r the p r e s e n c e of a prec ip i - t a t ing even t was a s s o c i a t e d wi th a n y o t h e r c h a r a c t e r i s t i c s o f each o f the t h r e e p a t i e n t g roups . T h e c h a r a c t e r i s t i c s s tud ied w e r e sex, m a r i t a l s t a tu s , age at o n s e t of i l lness , age at f irst admis s ion , l eng th o f i l lness a t index admiss ion , p rev ious epi- sodes, p rev ious admis s ion , d i s c h a r g e d to h o m e vs. d i s c h a r g e d to ins t i tu t ion , pre- morb id p e r s o n a l i t y , suicide a t t e m p t , educa t i on level, and pos i t ive f ami ly h i s t o ry for m e n t a l i l lness . T h e resu l t s were a l m o s t en t i r e ly nega t ive . Being f e m a l e p r e d i c t e d t he p r e s e n c e o f a p r e c i p i t a t i n g even t a m o n g un ipo la r a f fec t ive d i s o r d e r s a t the .01 p robab i l i t y level. H o w e v e r , when p o s t p a r t u m and m e n o p a u s e as p r e c i p i t a n t s we re exc luded , the d i f f e rence b e t w e e n m a l e s and f e m a l e s was no longer s igni f icant i nd ica t ing t h a t it was due to t hese two f ac to r s a lone . T h r e e ad- d i t iona l f indings we re s igni f icant a t t he .05 level. S c h i z o p h r e n i c s wi th a p r e c i p i t a n t w e r e m o r e l ike ly to be s ingle t han t hose w i t h o u t . F o r a f fec t ive d i so rde r , a f irst ep isode of i l lness was a s soc i a t ed with the p r e s e n c e o f a p r e c i p i t a n t w h e r e a s for s c h i z o p h r e n i a the oppos i t e was t rue . H o w e v e r , as each of the t h r e e p a t i e n t g r o u p s was t e s t ed for t2 va r iab les , t h r e e f indings a t the .05 level would not be i n c o n s i s t e n t wi th r a n d o m s a m p l i n g e r r o r and these r e su l t s would have to be i n t e r p r e t e d wi th th i s in mind.

D I S C U S S I O N

P r e c i p i t a t i n g even t s were found in a m iho r i t y o f a n y of the d i a g n o s t i c g rou p s . T h e y w e r e p r e s e n t in 35% o f the overa l l a f fec t ive d i s o r d e r s and in 11% of the sch izophren ics . T h e overa l l r e su l t s s u p p o r t a t r end for p r e c i p i t a n t s to be en- cowantered m o s t f r e q u e n t l y in u n i p o l a r a f fec t ive d i s o r d e r and l eas t f r e q u e n t l y in sch izophren ia , b ipo l a r a f fec t ive d i s o r d e r fal l ing in b e t w e e n . T h e d i f f e rence be- tween un ipo la r and b ipo la r i l lness d i s a p p e a r e d w h e n t h e y w e r e c o m p a r e d wi th p o s t p a r t u m and m e n o p a u s e exc luded . T h e r e f o r e this d i f f e rence is d,Je p .~mar i ly to t h e s e two fac to r s .

T a k i n g all alTective d i s o r d e r s as a g roup , p r e c i p i t a n t s w e r e fo~,and in 115 cases o r 35%. T h i s is in l ine wi th the f indings o f H u d g e n s et ai. ~ S t u d y i n g r ecen t life even t s in a g r o u p o f hosp i ta l i zed af fec t ive d i s o r d e r s d i agnosed by c r i t e r i a s imi l a r to ou r s , they found r ecen t life e v e n t s which could have c o n t r i b u t e d to the onse t o f the i l lness in a fou r th o f the p a t i e n t s . H o w e v e r , w h e n these p a t i e n t s w e r e corn-

2 0 0 C L A N C ' i r .ET AL .

pared to a conta-ol g r o u p of m e d i c a l pa t i en t s , s imi lar life e v e n t s w e r e f o u n d in the s a m e n u m b e r o f con t ro l s . T h e y w e r e unab le to find e v i d e n c e tha t r e c e n t life even t s w e r e i m p o r t a n t in b r ing ing on the d,~sorder. In view o f this, o n e would ex- p e c t t h a t as m a n y ,prec.ipi.tants would be found a m o n g the sch izophren ic s . O u r f inding of only t 1% is in s t r ik ing c o n t r a s t to th is expec t a t i on . T h e reason for this d i s c r e p a n c y is no t c lear . It may . r e f l e c t t h e views of the pe r sons t ak ing the his- tor ies t o w a r d the i l lness. T h a t is to say, a pe r son w h o r ega rds s ch i zoph ren i a as a biological p rocess would not s e a r c h fo r life even t s as ass iduous ly in s ch i zoph ren i a a s in a f fec t ive d i s o r d e r which is m o r e easily seen as a r e a c t i o n to such life even ts . This is only one exp lana t ion and u n d o u b t e d l y o t h e r f ac to r s c o n t r i b u t e d as we l l .

An a t t e m p t to find assoc ia t ions b e t w e e n t h e p r e s e n c e o f p r ec ip i t a t i ng f a c t o r s and o t h e r i m p o r t a n t a spec t s o f the clinical p i c tu re was a l m o s t en t i re ly nega t ive . The only s t r ik ing f inding w a s t h a t f e m a l e u n i p o l a r d e p r e s s i v e s w e r e m o r e l ike ly than m a l e s to have a p rec ip i t a t ing even t b e c a u s e of the in f luence o f ch i ldb i r th and m e n o p a u s e .

O u r f indings i nd i ca t e tha t p rec ip i t a t ing e v e n t s can be found a m o n g roughly a third o f affect ive d i s o r d e r s def ined by r e s e a r c h cr i te r ia and 1 1% of s ch i zoph ren i c s so def ined . T h e p r e s e n c e o f such even ts , howeve r , s e e m to have l i t t le re la t ionsh ip to p e r s o n a l o r social c h a r a c t e r i s t i c s o f pa t i en t s o r to the clinical p i c tu r e o f the i l lness.

C O M M E N T

In this s tudy we a re dea l ing with a p u r e . s a m p l e c o m p o s e d o f p a t i e n t s with p r i m a r y affect ive d i s o r d e r o r sch izophren ia . Exc luded f rom the s a m p l e w e r e pa t i en t s w i th s y m p t o m s tha t could b e a t t r i b u t e d to s o m e o t h e r k ind o f psy- ch ia t r i c d i s ea se o r phys ica l i l lness, and p a t i e n t s who showed a m i x t u r e o f a f fec t ive or s c h i z o p h r e n i c l ike s y m p t o m s , who a re o f t en d i a g n o s e d as schizo- p h r e n i f o r m or schizoaffec t ive psychosis . Even with such a sample , d e s i g n a t i n g a fac to r as a p rec ip i t an t and re la t ing it to the d e v e l o p m e n t o f t he i l lness is o p e n to a r g u m e n t . 'Stat is t ical e v i d e n c e to suppor t a pa r t i cu l a r posi t ion can also be at- t a c k e d in a va r ie ty o f ways. T h e a u t h o r s th ink it useful to e x a m i n e popu l a r th ink ing abou t life e v e n t s and the i r r e la t ionsh ip to behav io r bo th in h e a l t h and in m e n t a l d isease . It m a y be that the concep t o f a p rec ip i t a t i ng o r causa t ive f ac to r is a n e c e s s a r y par t o f a co l lec t ive ra t ional s y s t e m o f t h o u g h t which is appl ied both to n o r m a l behav io r and behav io r a s soc ia t ed with d i sease .

I t is g e n e r a l l y a c c e p t e d tha t life e v e n t s c a u s e c h a n g e s in feel ing and m o o d s ta tes . T h e s e c h a n g e s a r e r e g a r d e d as par t of n o r m a l funct ion . In fact , a b s e n c e o f t he se ch~tnges m a y be r e g a r d e d by socie ty as e v i d e n c e o f i l lness. T h e - r a n g e and in tens i ty o f t hese r e s p o n s e s m a y vary g r ea t l y as for e x a m p l e in the e c s t a s y o f a rel igious e x p e r i e n c e or t he d e p t h s o f s adnes s in a b e r e a v e m e n t and ye t be re- g a r d e d as no rma l . N o r has an a p p r o p r i a t e d u r a t i o n for such feel ing s t a t e s been c lear ly def ined . T h e m o u r n i n g per iod , e.g., g ives s o m e publ ic recogni t ion and cons ide ra t i on for t he pe r son who is so b e r e a v e d , but it still r ega rd s the pe r son as being wi thou t d i sease . The bereavemer, . t is a sufficient exp l ana t i on in i t se l f for any a l t e r a t ion in e m o t i o n a l o r mood s ta te . Wi th in ce r t a in l imits , e x t r e m e s o f t h o u g h t and be l i e f a re also a c c e p t e d by socie ty and a re exempl i f i ed in :the unusua l bel iefs he ld by ce r t a i n re l ig ious sects . T h e s e a re s o m e t i m e s a t t r i b u t e d to a re l ig ious e x p e r i e n c e u n d e r g o n e by o n e or m a n y m e m b e r s o f the secL S u c h e x p e r i e n c e s o r

SCHIZOPHRENIA A N D P R I M A R Y AFFECTIME DISORDER 201

conve r s ions also fall within, the ca t ego ry o f life evepts . E x t r e m e s of behavior and e c c e n t r i c p r a c t i c e a r e u n d e r ce r ta in c i r c u m s t a n c e s also p e r m i t t e d by society. T h e s e e x a m p l e s point -to the a c c e p t a n c e of" an int,ense or unusual . l ife-event as a sufficient r e a s o n for socie ty to t o l e r a t e ce r ta in dev ia t ions f rom usual p a t t e r n s o f t h ink ing , behavior , or feeling. T h e y a r e not neces sa r i l y classif ied as.a d i sease be- :cause they a r e d i f f e r e n t , in tense , o r p ro longed , and the life even t s which p r e c e d e d t h e m a r c a par t o f t h e ins t i tu t iona l i zed ex,planat ion for the i r t o l e r a n c e . S imi la r e x t r e m e s o r dev ia t ions a re also a f e a t u r e o f cer ta in d i sease s ta tes , bu t a dis- t inc t ion o f w h a l is a d i s ea se and what is n o r m a l on :the basis o f t h e s e f e a t u r e s is not a lways poss ib le . T h e c o n c e p t o f a l ife even t o r p rec ip i t a t ing factor , r ega rd l e s s o f how i m p r o b a b l e it m a y be, is also i nvoked to exp la in behav io r wh ich is a s y m p t o m of d isease . R e g a r d l e s s o f iss t rue et iology, " ' some th ing h a p p e n e d t o h i m " is the s imples t exp lana t ion . T h r o u g h h is tory prac t ica l ly every c o n c e i v a b l e s i tuat ion or even t has been invoked as an exp lana t ion for abe r r a t i ons o f peop le ' s behavior . I t is a t rad i t ion long ins t i tu t iona l i zed in society, and it is not surpr is ing tha t we c o n t i n u e to s ea rch for it or, as a coro l la ry , we a r e r e l u c t a n t to give up t he sea rch .

The i m p o r t a n c e o f a p rec ip i t a t ing fac to r may also be re l a t ed to the var ious theor i e s o f m e n t a l d isease . S i eg le r and O s m o n d 5 have a r r a n g e d these theo r i e s into m o d e l s tha t e m b r a c e medica l , p sychoana ly t i c , social, mora l , family in t e rac - t ional, consp i ra to r ia l , and impa i r ed app roaches . T h e s e m o d e l s have been s tud ied and c o m p a r e d in a n u m b e r of d i m e n s i o n s such as e t io logy, def ini t ion o r diagnosis , t r e a t m e n t , p rognos i s , r ights and du t i e s o f society, etc . T h e un ique c h a r a c t e r o f the med ica l m o d e l is tha t it g ives the sick individual a special pr ivi leged "'sick ro le" which re l ieves h im o f b l a m e for his i l lness, and excuses h im o f his usual obli- ga t ions for vary ing pe r iods o f t ime . In turn , the sick pe r son has the ob l iga t ion to t ry and ge t well , a n d to c o o p e r a t e with those , such as phys ic ians , who might assist h im. 6 U n d e r the med ica l mode l i t is not n e c e s s a r y to knox,," the e t io logy o r the cause o f an i l lness in o r d e r to m a k e a d iagnos is and provide t r e a t m e n t . But in an a t t e m p t to p rov ide s o m e ra t ional basis for i l lness in a c c o r d a n c e with soc ie ty ' s ex- pec ta t ions , we as phys ic ians m a y offer s o m e exp lana t ion by way o f a p rec ip i t a t i ng even t or s i tua t ion. This is pa r t i cu l a r l y l ikely to o c c u r w h e n the e t io logy o f the i l lness in ques t ion is i n c o m p l e t e or poor ly u n d e r s t o o d .

In every o t h e r mode l o f i l lness s o m e b o d y o r s o m e t h i n g m u s t a lways be b l a m e d 3 In the mora l m o d e l the cause is in the i m m o r a l i t y o f the pe r son . T h e social m o d e l loca tes the t roub le in society; the pa t i en t is a vict im, and the cause o f t he t roub le lies in o n e o r m a n y o f the mul t ip l e p r o b l e m s tha t socie ty m a k e s for the individual . T h e p s y c h o a n a l y t i c m o d e l sees t h e signif icant e v e n t in s o m e e r r o r o r omiss ion by a pa r en t . T h e family i n t e r ac t iona l m o d e l s p laces the cause o f t he t roub le in the fami ly and the ident i f ied pa t i en t is on ly ex t e rna l i z ing th rough his s y m p t o m s an i l lness which is i n h e r e n t in the family itself. T h e consp i ra to r i a l mode l s is seen as a plot in which socie ty , famil ies and hospi ta l s t a f f c o m b i n e to de- pr ive the pa t i en t o f his l iber t ies . As previous ly s t a t ed all o f t h e s e m o d e l s o f i l lness impl i ca t e s o m e ou t s i de sou rce as con t r i bu t i ng to the p a t i e n t ' s i l lness, and is a neces sa ry c o m p o n e n t o f the theory . This does not m e a n t he t heo ry is co r rec t .

Psych ia t r i s t s a r e no t cons i s t en t in the i r t heo re t i ca l a p p r o a c h to d i sease and t r e a t m e n t and t e n d to use a n u m b e r o f the m o d e l s d e s c r i b e d above. D e p e n d i n g upon the mode l used and the d i sease in ques t ion the need for an exp lana t ion o r

20,2 .CLANCY ET A L

causat ive factor will vary. T h e psychia t r i s t .who, e.g., a ccep t s depress ion as a disease u n d e r the medical model does not need a cause or explanat ion to m a k e a diagnosis o r provide t r e a t m e n t . Unde r ano the r model some cause o,r even t is necessa ry before proceeding with t r e a t m e n t on a rat ional bas i s . .Hence the need for.a p r e c i p i t a t i n g o r causat ive fac tor is sustained, at least a t a theore ' t ical level.

Prec ip i ta t ing f a c t o r s seem to b e .of tess concern in chronic illness. Schizophrenia is a chronic disease and a propor t ion of depress ives a re subject to recur ren t a t t a cks of illness. The person who is chronical ly ill may b e t h e un- fo r tuna te benef ic iary o f the impai red role. The impaired person is seen as " 'd i fferent ," he may be blind, deaf, para lyzed or men ta l ly ill, but once impaired it does no t m a t t e r how he got his impa i rment . The impaired person is expected to behave as normal as possible and not to fuss abou t his handicap. T r e a t m e n t , with a goal of cure is not in quest ion and rehab:.litation has a more modes t goal o f res- torat ion of function but with con t inuance of the handicap. Per ris u repor ted prec ip i ta t ing .factors occur r ing within three mon ths :in a propor t ion of subjects before .the first episode of b ipolar o r unipol~r depressive illness. Relapses , however , seemed to occur independent ly from precip i ta t ing factors . This may mean that precipi ta t ing fac tors a re less influential in chronic illness, but it could also mean that they a re not necessary and are not sought for under the impai red model .

S U M M A R Y

A sample of 200 schizophrenics and 225 p r i m a r y affective d isorders was se- lected on the basis o f rigid d iagnos t ic cri teria, from hospital records. An a t t e m p t was made to find associa t ions between prec ip i ta t ing factors , d iagnost ic groups , and ce r t a in pa t ient and clinical charac ter i s t ics . Our findings indicate tha t precipi- tat ing events can be found in 35% of p r ima ry affective d isorders and 11% of schizophrenics. The re is a t rend for prec ip i tan ts to be seen most f requent ly in unipolar affective d isorder and least f requent ly in schizophrenia , b ipolar affective disorders falling in between. Prec ip i ta t ing events, however, seem to have l i t t le relat ionship to personal or social charac te r i s t i cs of pat ients o.r to the clinical pic- ture o f the diseases studied.

R E F E R E N C E S

1. Morrison J, Clancy J. Crowe R et al: The Iowa 500: Diagnostic validity in mania, depression and schizophrenia. Arch Gen Psy- chiat 27:457, 1972

2. Feighner JP, Robins E, Guze SG, et al: Diagnostic criteria for use in psychiatric re- search. Arch Gen Psychiat 26:57, 1972

3. Diagnostic and Statistical Manual of Mental Disorders, Washington, DC, American Psychiatric Association, 1968

4. Hudgens RW, Morrison JR, Barchha, RG: Life events and onset of primary affective disor- ders. Arch Gen Psychiat 16:!34, I967

5. Siegler M, Osmond H: Models of madness. B r J Psychiatry 112:1193, 1966

6. Parsons T: The Social System. New York, Free Press, 1951, p 428

7. Osmond H: Love it or leave it: The medical model and psychiatry. From an address given at the Tenth AnniversaD' of the opening of the Psy- chiatric Department of Sibley Memorial Hos- pital, 1971

8. Meissner, W: Thinking about the family- psychiatric aspects. Faro. Process 3: i, 1964

9. Perris C: The separation of bipolar (manic depressive) from unipolar recurrent depressive psychoses. Behav Neuropsychiatry 1:17, 1969