Experiential variables

'Experiential' is a useful term to refer inclusively to all that individuals are exposed to, from conception to death. In epidemiological research, it includes intrauterine exposures—such as maternal influenza or malnutrition—and perinatal events. In infancy and childhood, social and interpersonal experiences have been the main focus of research. Maternal deprivation was intensively studied in both clinical and community samples for two decades. The expectation from Bowlby's attachment theory was that loss or separation from the mother would be pathogenic for depression and possibly personality disorders. (7:!> This hypothesis has proved very hard to test because of confounding by other factors. Where people have lost their mother through death or separation, a number of other disadvantageous experiences are also likely to have been present. Maternal deprivation promised to be an important topic both for psychiatric theory and for social policy. The evidence has been assembled by Rutter(72) who concluded that '...the residual effects of early experiences on adult behaviour tend to be quite slight because of both the maturational changes that take place during middle and later childhood and also the effects of beneficial and adverse experiences during all the years after infancy...'.

More recently, promising findings have been obtained on the association between parenting style and depressive disorders in adulthood. Parker (73Z4) developed the Parental Bonding Instrument (PBI) to measure two fundamental dimensions of the manner in which parents behave towards their children: care and affection as one dimension and protectiveness as the other. Studies of clinical samples using PBI have suggested that low parental care and parental overprotection, separately or together, are associated with some psychiatric disorders in adult life. The 'toxic' exposure was found to be affectionless control: that is, parents who had been highly controlling but not affectionate or caring. Parker (75> has reviewed the evidence for inadequate parental care as a risk factor to adult depression, integrating this with the evidence on parental loss and, importantly, on compensating or mitigating factors. The PBI is too lengthy for epidemiological research on community samples where the interview is often already extensive. Parker and his colleagues have subsequently developed a briefer instrument, the Measure of Parenting Style ( MOPS), which includes the experience of physical and sexual abuse. (76> MOPS is likely to prove useful in case-control and prospective studies of psychiatric disorders for systematically obtaining information on exposures of theoretical relevance.

Childhood abuse

It seems intuitively likely that children who have been physically or sexually abused have an increased risk of having anxiety, depression, or other psychiatric disorders in adulthood. The findings from epidemiological studies on unreferred samples point to the many other adverse experiences that accompany childhood sexual abuse, including physical violence, unstable and untrustworthy relationships with parents, and emotional deprivation. (ZZ> Knutson(78) has given a review of the psychological consequences of physical abuse in childhood. Valuable reviews on the consequences of sexual abuse can be found in Browne and Finkelhor (79> and Beitchman et al.(80)

Recent exposure to adversity

Adverse experiences have been very extensively studied for their contribution to the onset and course of psychiatric disorders. In epidemiological research, much attention has been accorded to issues that arise in the measurement of adversity. Some of these issues are equally relevant in clinical practice. They include the following.

• The duration of the stressor: acute or long-standing.

• Its magnitude and how to determine this independently of the person's reaction to it.

• The independence of the event from the individual: some events are entirely independent while others may have come about because of the individual's own behaviour or psychiatric state.

• Interaction with sociodemographic variables: the same experience may have markedly different significance according to these.

• The personal context of the experience may augment or reduce its psychological impact.

• Confounding by personality traits that may be independently associated with psychiatric morbidity.

• The additive effect of multiple events, some of which may be causally linked in a chain.

• Effort after meaning, whereby patients and doctors may attribute symptoms to a particular experience as a way to explain the onset of illness.

These issues have been comprehensively described in Katschnig (81 and in Brown and Harris.(82) A valuable conspectus of the issues and the evidence is in the volume edited by Dohrenwend.(83) Instruments for measuring life events are of two types. The most simple are brief inventories, usually for self-completion. An example is the measure by Brugha et al.(84) A radically different approach is to make the assessment interviewer based. First the adverse experiences are identified at interview from a very full list, then the overall context for that person is determined. But the rating of severity is made by the external judgement of a research team. This method, the Life Events and Difficulties Schedule, was developed by Brown and his colleagues and is recognized to obtain high-quality information. (85> Dohrenwend et al.(86) have also developed a comprehensive assessment for administration by interview. (Life events are discussed further in Chiapter,2:6.1,.)

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