Developmental Psychiatry Section, Department of Psychiatry, Cambridge University Clinical School, Douglas House, 18b Trumpington Road, Cambridge CB2 2AH, UK
Declaration of interest None. I.M.G. is supported by the Wellcome Trust and this review was carried out within the MRC Cooperative for Brain, Behaviour and Neuropsychiatry.
* The Rutter Lecture; delivered at the Faculty of Child and Adolescent
Psychiatry Residential Conference, University of York, 5 October 2001.
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ABSTRACT |
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Aims To explore sources of evidence and suggest future lines of research to clarify the relationship between exposure to negative circumstances and development of psychopathology in young people.
Method Selective survey of the literature to collect a series of hypotheses that might serve as a framework for future research.
Results and conclusions Evidence to date suggests there is no simple relationship between adverse life events and the subsequent emergence of psychopathology. The interplay of acute and chronic stressors over the lifespan with affective temperament; the interrelationship of sensitivity and performance cognitions in response to life events; and limbic-cortical neural networks are all indicated as important avenues of future research.
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INTRODUCTION |
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Determining the causation of common emotional and behavioural disorders in young people requires an extension of current social inquiry interview procedures to characterise the neurocognitive processes through which life events and difficulties exert their effects. It is suggested that this can be achieved by incorporating experimental methods of assessing psychological functions and mapping these to neural systems underpinning these functions at different stages of development. Putative intermediate neurochemical systems will not be discussed, although it is acknowledged that their modulating effects may shape the structure and function of the social and emotional brain over time (Goodyer et al, 2001).
A tentative theoretical framework for further research is proposed, based on some selected illustrations from findings on affective disorders in young people as well as data from studies on adults. Although primarily focused on affective disorders, the framework has implications for life events research in behavioural syndromes as well.
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LIFE EVENTS AS CAUSAL PROCESSES IN PSYCHOPATHOLOGICAL CHANGE |
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Martha Rueter and colleagues (Rueter et al, 1999) investigated the interdependence between persistent parental disagreements and psychiatric symptoms in 13-year-old adolescents over a period of 4 years, and re-interviewed the young people at 19-20 years of age for assessment of emotional disorders. The direct predictors of disorder at age 19-20 years were higher self-reported depression scores at age 13 years and rising depression scores over the subsequent 3 years, the two being correlated. Interestingly, parental disagreements at each year point did not directly predict onset but were crucial moderators of the change in depression scores over time. Increases in parental disagreements correlated with increases in self-reported depressive symptoms. Thus, chronic parental disagreements appear to be slow but relentless producers of depressive symptoms leading to subsequent later clinical disorder. Whether highly specific proximal life events involving peers would have altered the nature of these relationships is not clear, as these were not independently measured. It may also be that social inquiry methods underrecorded important private events such as intrafamilial physical and sexual abuse, which are particularly likely to be correlated with subsequent psychopathology. Such experiences could be embedded in the broader non-specific category of family discord. Nevertheless, these longitudinal observations suggest an evolving psychosocial process over midadolescence exerting significant effects on onset of anxiety and depressive disorders by late adolescence.
Overall, throughout the main adolescent period of risk of affective disorders there appears to be both a fast and a slow pace of onset for first-episode unipolar major depression. Both types seem likely to arise from the same broad set of family risk environments within which a greater understanding of the effects brought about by physically and sexually abusive events is essential. Fast-onset affective disorder appears to be rapidly induced in many teenagers by a highly toxic and rather specific event involving acute peer-group dysfunction or (less commonly) severe loss. If there is not a rapid effect, it looks as though negative life events contribute as further slow burn experiences, increasing the liability to onsets evolving by early adult life. Fast-onset events are not specifically associated with a highly emotional temperament: thus, serious disappointments appear to arise more from the ebb and flow of normal adolescent peer-group relations than individual differences in behavioural style.
What precise pathological psychological effects occur within people following exposure to adverse life experiences remains unclear. Investigating this question requires more direct assessment of the mental functions of adolescents who have experienced different types and patterns of personally negative events and difficulties over time.
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THE NATURE OF MENTAL FUNCTIONS |
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The sensitive mind and social adversity
Aaron Beck postulated that affective disorders arise from a set of negative
cognitive self-schemas whose origins and formation occur following exposure to
adverse early experiences (Beck,
1967). He suggested that these are latent and not accessible to
consciousness, until activated by subsequent negative social experiences.
Under such circumstances individuals will experience dysphoric mood and, if
they possess a negative latent schema, will consciously experience a
clinically impairing level of self-devaluative thoughts. Over the past two
decades increasing evidence has noted that dysphoric mood is a critical
activating factor, as negative latent schemas are not present in neutral mood
alone. There is therefore a crucial distinction to be made between emotionally
cold and hot cognitive processes
(Teasdale & Barnard, 1993;
Teasdale et al,
1998). Cold cognitions are thoughts about the self that are
conscious, intellectual and considered without associated affect. Hot
cognitions are those in which affective tone is an integrated component of the
thoughts. It is the latter form that appears to be more characterised by an
increase in the number of self-critical, blaming and derogatory comments. This
suggests that it is the activated emotional mode that might be a distinctive
indicator of abnormalities of sensitive mind evolving as a consequence of
social adversity. Whether in young people hot cognitions of this type are
captured to a sufficient degree by self-reports of cold cognitive measures
such as self-esteem is unclear. Three modes of processing emotional material
have been proposed: mindless emoting;
conceptualising/doing and mindful experiencing
(Teasdale, 1999). It is the
latter mode that is postulated as the only way to process negative emotion
effectively. Whether these three forms of emotion-processing are truly
independent and associated with different types of social experiences
good or bad is not known.
Negative self-schemas, temperament and social adversity in
adolescents
Kelvin and colleagues have established that latent negative schemas exist
in normal adolescents with no previous lifetime history of psychopathology
(Kelvin et al, 1999).
Activation of dysphoric moodcongruent self-devaluative thoughts (hot
cognitions) was specifically associated with the enduring temperamental style
(present for at least 3 years) of high emotionality in both genders. This
association was neither a function of the level of induced dysphoria nor
associated with mean scores of self-reported current depressive symptoms or
self-esteem (cold cognitions), suggesting that emotion-focused cognitions are
different from those obtained in self-reports of mood and feelings. A
significant association between negative maternal experiences during infancy
and dysphoric congruent self-devaluative thinking in 5-year-old children
during a hot cognitive task has also been reported
(Murray et al, 2001).
The findings from these two studies suggest critical interplays might occur
between temperamental vulnerabilities and adverse social environments during
development that predispose to evolving negative affectivecognitive
schemas from middle childhood through adolescence. It may be that there is a
temperamental predisposition within the child for the inception of latent
negative cognitive schemas whose formation is dependent on subsequent ongoing
family adversity. The corollary is that there might be a decreased tendency to
form negative affectivecognitive schemas following exposure to such
adversities in those who are not temperamentally at risk.
The performing mind and coping with life events
Ruminating on dysphoric congruent self-devaluative thinking has been
proposed as the psychological element that results in persistence of
self-devaluative thoughts in consciousness through a failure to process
dysphoria (Nolen-Hoeksma & Morrow,
1993). Rumination may indicate an active strategy engaged to avoid
emotionally painful experiences. If so, there is a clear cost in terms of
narrowing cognitive flexibility, at least in the short term. Alternatively,
this ruminative process might implicate a putative role for performance
weaknesses in emotion processing and coping with the psychological
consequences of social adversity. If some adolescents have weaknesses in
cognitive control processes, then modulating the mood-congruent effects of
undesirable life events and difficulties might be inefficient and lead to
impaired coping with environmental demands. Remarkably little is known about
the putative role of executive processes involved in coping with social
adversity, although neuropsychological impairments in depression have
attracted considerable research interest
(Austin et al, 2001).
Thus, the following account is tentative and is aimed at generating hypotheses
for further investigation.
Coping refers to a collection of internal responses to external events whose functions are to ameliorate the liability to distressful outcomes. A number of distinct processes contribute to adequate coping, including problem-solving ability, controllability of the situation and appraisal of circumstances. Although there is considerable interest in children's ability to information-process social experience, how psychological coping strategies are activated following exposure to life events has received little research attention. A preliminary investigation of these relations has been carried out using a casecontrol sample of 30 recently depressed adolescents and 48 control participants matched for age, gender and general intelligence, who took part in a series of evaluations documenting concurrently their social coping and executive skills. Participants were first asked to recall and describe an undesirable life event and then complete a self-report coping questionnaire recording how they would expect to respond to that specific circumstance (Kyte, 2002). The instrument measured four styles of coping: active, distraction, avoidance, and seeking support (Ayers et al, 1996). Participants then completed selected tests of cognitive performance covering three processes considered likely to be recruited when organising an event-driven response: flexibility of attention, behavioural inhibition and decision-making (Sahakian & Owen, 1992). For active and distraction coping styles there were moderate and strong associations with behavioural inhibition and decision-making abilities, respectively, in both case and control groups, but no association with flexibility of attention in either group. These associations were strongest for adolescents who recalled personal disappointments or losses. Avoidant coping was more prevalent among participants with depression when recalling any form of undesirable life event, and these individuals were also less efficient in both the behavioural inhibition and decision-making tasks. These cross-sectional patterns in adolescents with depression suggest not only potential performance differences that might be a consequence of psychopathology, but a loss of connection between coping and executive skills, which is retained by members of the control group. It is not yet known whether executive performance varies with temperamental style, but negative emotionality is associated with the pattern of children's coping style following divorce (Lengua et al, 1999). Adverse experiences may therefore exert greater negative influence on the nature of mental performance than has been considered hitherto, a possibility that is also suggested by recent longitudinal findings that the offspring of women with postnatal depression show significant deficits in general cognitive abilities in the subsequent childhood years (Hay et al, 2001). Whether these effects are mediated by a negative temperamental style or by physiological processes (such as changes in neurochemical performance) requires further research.
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MENTAL COHERENCE TO SOCIAL ADVERSITY |
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What seems crucial is that this proposed model for processing social experience operates most effectively when the mind is emotionally hot. This makes efficient emotion processing a key first step of the overall response to social adversity.
If the findings to date are treated as hypothesis-generating, then the level of psychiatric risk following exposure to undesirable life events and difficulties might be related to one or more of three intermediate cognitive endophenotypes: over-sensitive response to the associated emotional tone of the experience; weak control functions, allowing for a disorganised behavioural response; and failure of overall mental integration such that sensitive and control processes lack synchrony. Who might be most liable to these processing weaknesses? Adolescents at high psychosocial risk of psychopathology are likely candidates, perhaps specifically those with latent negative schemas themselves derived from earlier adverse experience.
Prospective studies need to determine the concurrence and coherence of sensitive and performance mental functions in both cold and hot cognitive states through the developmental period of adolescence. This is likely to require the incorporation of challenge or demand paradigms in study designs and the relation of these to the nature of both recent and past social adversities. This methodological issue is clinically as well as theoretically relevant, as choice of treatment may depend not only on the clinical features and social environment but also on the characteristics of sensitive and performance mental functions the psychological endophenotype.
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THE NEURAL BASIS OF PSYCHOLOGICAL RESPONSE TO LIFE EVENTS |
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Although the basic programming of these neural networks is genetic, the fine-tuning most probably occurs through social experience in childhood and adolescence (Paus et al, 2001). Animal studies have shown deleterious consequences of social stress on neural structure and function, implicating an effect of the social environment on brain through the physiological consequences of persistent interpersonal difficulties (McEwen, 1998). Determining the relative effects of chronic and recent life events and difficulties on the patterning of psychological functions and their related neural structures is a major goal of future developmental research. Such vertically integrated science will provide important clues about the interplay between social experiences, mental processes and their neural substrates (Posne & Rothbart, 2000).
The clinical implications of such research could be far-reaching. They include identifying socially at-risk populations by their psychological and neural patterns of response to different life event tasks both off-line (outside of the scanning environment) and on-line (using functional magnetic resonance); understanding the nature of developing neurocognitive systems following exposure to different patterns of social adversity through childhood and adolescence; delineating weaknesses and deficits in different components of the limbic-cortical circuit, thereby opening the opportunity for new targets for treatment; and documenting neurocognitive change in patients following treatment.
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ACKNOWLEDGMENTS |
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Received for publication December 6, 2001. Revision received May 7, 2002. Accepted for publication May 9, 2002.