A comparative study on distressful events in affective disorder and normal control

Background: Life events’ stresses are concerned with situational encounters and the meaning that a person attaches to such encounters. It refers to our feeling; it is something of importance to us and is being jeopardised by events in our daily life, and the stressful life events are causally linked to a variety of undesirable effects which infl uence our performance and health. Aim: This study was planned for assessment and comparison of stressful life events between mood disorder and normal people. Materials and methods: In this study, total 90 participants (30 manic patients, 30 depressive patients, and 30 normal participants) were recruited and severity of symptoms was assessed by Young Mania Rating Scale and Beck Depression Inventory. Normal participants were screened by General Health Questionnaire. Presumptive Stressful Life Events Scale was used for both groups for assessment of stressful life events. Findings and conclusion: The present study results revealed that clinical group had higher score on stressful life events as compared to normal participants. Patients with depression had more stressful life events as compared to the mania and normal population. Overall, life events precede the mood symptoms’ occurrence.


Introduction
Depression is a mood disorder in which main symptoms are related with mood disturbance, thought process, sadness, loneliness, hopelessness, self-doubt, and guilt.Depression could be divided into two major categories in which fi rst is known as mild depression.It is known as mild because it has eff ect on daily life but at minimal level.In major depression type of categories, symptoms infl uence person's ability to deal with daily life activities.Periods of depression usually last from a few weeks to many months, but a period lasting for several years is not uncommon.[1] In mania, most frequent symptoms include hyperactivity, reduced need for sleep, racing thoughts, irritability, elation, aggressiveness, and delusions of grandeur.
A person with pessimistic thinking is more vulnerable to depression and mood disorders when he or she experiences negative events in life.[1] Behavioural views of aff ective disorders focus on types of reinforcement by reducing negative consequences and increasing positive reinforcements.Th e emotional or psychodynamic perspective returns to early parentchild and early caregiver-child relationships.Th e emotional perspective again believes that disruptions and inadequacies in early child relationships open the door to mood and aff ective disorders.Sociocultural components include low self-esteem and insuffi cient support systems with relation to 'gender or socioeconomic factors' .[2] Mathew et al. [3] conducted a study in which they included 46 manic patients and they assessed their life events during a period of six months before and aft er illness started.In their study, they found stressful life events were signifi cantly higher before the fi rst episode compared to aft er episode, and they also found that life events before illness were signifi cantly associated with male patient and with a younger age of onset.[3] A recent study done by Rodrigo et al. in Asian country indicated that symptoms of depression were signifi cant in 37.5%; they also found that patients and their caregivers showed strain which were associated with interruption to work and disputes with relations.[4]

Methods
In the present study, sample comprised of 90 subjects (30 manic patients, 30 depressive patients, and 30 normal participants).Th ose patients fulfi lling diagnosis criteria according to ICD-10 were included.[5] Th eir age range was between 20-50 years.Participants were able to read Hindi.Th ose having comorbid psychiatric illness or having bipolar disorder and presence of any major medical or neurological illness were excluded from the study.

Research design
Th e study was cross-sectional in nature and those participants fulfi lling the criteria were selected.

Setting
Th e study was conducted in Psychiatry Department, Pt BD Sharma PGIMS, Rohtak.

Duration of the study
Th e study was conducted during May to October 2014.

Socio-demographic proforma and clinical data
A proforma was specially designed for collecting information about socio-demographic and clinical variables of sample.It included information such as age, sex, residence, marital status, education, occupation, duration of current episode, history of present illness, number of previous depressive episodes, signifi cant past psychiatric history, signifi cant medical history, family history of medical illness, family history of psychiatric illness, signifi cant personal history, and diagnosis.

Young Mania Rating Scale
Young Mania Rating Scale (YMRS) was developed by Young et al. in 1978 to assess the severity of manic symptoms.[6] YMRS consists of total 11 items.Beck Depression Inventory-II: Beck Depression Inventory-II (BDI-II) was developed by Beck et al. in 1996 to assess the level of depression.[7] Th is scale consists of 21 items.General Health Questionnaire (GHQ): General Health Questionnaire (GHQ) was used as a screening instrument to identify psychological distress among adults.[8] GHQ consists of 28 items.Presumptive Stressful Life Events Scale: Presumptive Stressful Life Events Scale (PSLES) was developed by Singh et al. in 1984.[9]Th is scale consists of 51 items which is divided into two categories, i.e. past and present.

Statistical analysis
Statistical Package for Social Sciences (SPSS-16) was used for analysis.Data was assessed using mean and standard deviation, independent samples t-test discrete variables for comparisons.

Results
Th e general characteristics of the participants such as sample size, age, sex, occupation, marital status, and education were equally distributed.Total 90 participants were selected (clinical population=60 [30 mania, 30 depression], normal population=30).In the descriptive analysis of mean and standard deviation of the socio-demographic details, both the clinical and normal groups were comparable.
Table 1 shows results of the stressful life events in the previous year, past life, and total score on PSLES between patients with mania, depression, and normal population.In the previous or one year before illness was started, in past years, and in total, stressful life events were found higher in clinical group as compared to normal group.Overall, total score showed that clinical population had signifi cant higher stressful life events than normal participants.
In Table 2, t-test was calculated to compare the stressful life events in three conditions which was, in the recent one year, in past years of life, and total score on PSLES.Results showed signifi cant diff erence in the total score that predicted that life events which occurred during whole life infl uenced the psychological health.
Table 3 shows the results of various domains in PSLES between patients with mania, depression, and normal population.Clinical group have higher score in the domains of bereavement, education, family & social (manic), fi nancial, health, legal (depressive), marital & sexual, and work of PSLES compared to normal control.

Discussion
In the present study, age range of the sample was 20-50 years.Most of the patients were diagnosed in early adulthood.Participants varied in education from illiterate to graduation in both groups; in clinical group, it was found that most of the patients either had no formal education or education up to secondary level.In sex ratio, aff ective disorder was found equally in both male and females.In this study, onset of illness was found in early 20's, and duration of illness was chronic and episodic in nature.Stressful life events in the previous one year, past, and total score was found signifi cantly higher in the clinical group than normal group.Manic patients had higher score in past years on PSLES as compared to depressive patients and patients with depressive disorder had higher score in overall total score.Overall results showed that clinical population had signifi cantly higher stressful life events than normal participants.In support of present study, literature has also found a positive association between life events and aff ective episodes.[10] A study conducted by Kumari and Jahan [11] showed that distressful life events were present in all three groups.However, life events of manic group were mainly related to social life, whereas life events of depressed and normal subjects were mostly related to personal life.[11] Hosang et al. [12] conducted a study in which they found stressful life events to be signifi cantly associated with unipolar depression and bipolar disorder.In a recent study done by Koenders et al., [13] they found that negative life events were signifi cantly associated with both types of mood disorder.
Our study showed the results in the domains of PSLES which were family & social, fi nancial, work, marital & sexual, health, education, legal, courtship & cohabitation, and bereavement.Descriptive analysis was done in which the results were found that clinical group had higher score in health, family & social, fi nancial, work, marital & sexual, and bereavement in patients with mania whereas in depressive patients results were found that they had higher score on fi nancial, work, marital & sexual, bereavement, legal, health, and education.Both clinical and normal In favour of result of the present study, a study conducted by Proudfoot et al. [14] found that psychological stress acting as trigger was specifi cally associated with the onset of manic/ hypomanic episodes/depressive episodes.To know about the role life events play in genesis of disorders, Medhi and Das [15] used the PSLES.Number of life events and total life events scores were signifi cantly higher in depressive group than control group.Close association of bereavement and depression was observed.[15] Ghosh and Dutta [16] used PSLES to assess life event in major psychoses including mood disorder.Mood disorder patients involve both mania and major depression.[16] Th ey found close relation of major life events with depression and mania, and specially mentioned bereavement as a life event.[16] Limitation and future direction Present study was conducted on a small sample size.Hence, result of the present study cannot be generalised.Structured diagnostic tool had not been used to confi rm the diagnosis.Study was cross-sectional in nature.In future, this study can be done on a large sample.In the present study, we assumed that stressful life events were signifi cant between patients of aff ective disorder and normal population.We found signifi cant diff erence in the stressful life events between all three groups.

Conclusion
Overall signifi cant diff erence was found between both groups in PSLES; clinical population had higher score than normal population and both groups had higher score in previous year of stressful life events.Life events appeared before the occurrence of mood symptoms.In the study, signifi cant diff erence was found in clinical as well as in between mania and depression also.Signifi cant fi ndings were found that both groups had higher score on the family & social domain of PSLES.Our study assessed these fi ndings in Indian context.

Table 1 :
Mean and standard deviation of stressful life events in previous year, past life, and total score between patients with mania, depression, and normal population PSLES=Presumptive Stressful Life Events Scale group had higher score in the family & social as compared to other domains; it means that family & social domain had signifi cant role and infl uence in the life of both the groups.

Table 2 :
t-test between patients with mania, depression and normal control

Table 3 :
Descriptive statistics between patients with mania, depression, and normal control on various domains of PSLES