Comprehensive Psychiatry

Official J o u r n a l o f .the A m e r i c a n , P s y c h o p a t h o l o g i c a l A s s o c i a t i o n

VOL. 14, N O . 3 M A Y / J U N E 1973

The Iowa 500: Precipitating Factors in

Schizophrenia and Primary Affective Disorder
J o h n Clancy. R a y m o n d C r o w e . G e o r g e W i n o k u r . a n d J a m e s M o r r i s o n

E h a v e p r e v i o u s l y d e s c r i b e d a s a m p l e o f 525 hospitalized p a t i e n t s suffering

W from p r i m a r y affective disorder o f schizophrenia. ~ T h e s a m p l e w a s se-
l e c t e d from hospital records 2 5 - 3 5 y e a r s ago and d i a g n o s e d on the basis of re-
s e a r c h criteria d e s c r i b e d by F e i g h n e r e t a l / W e are o f the opinion that w e h a v e
isolated h o m o g e n e o u s d i a g n o s t i c g r o u p s for study. F u r t h e r m o r e , in r e s p e c t to t h e
question o f d i a g n o s t i c validity w e found that in 2 0 0 s c h i z o p h r e n i c p a t i e n t s
d i a g n o s e d a c c o r d i n g to the criteria w e used t h e r e w a s chart a g r e e m e n t in 95%,
and in 325 affective d i s o r d e r s there w a s 93% a g r e e m e n t with the original chart
d i a g n o s i s b a s e d on the revised classification a d o p t e d by the A m e r i c a n P s y c h i a t r i c
A s s o c i a t i o n o f 1934.:~
T h i s p a p e r d e a l s with precipitating f a c t o r s in r e s p e c t to a n u m b e r o f c h a r a c -
teristics o f p a t i e n t s d i a g n o s e d as p r i m a r y affective disorder or s c h i z o p h r e n i a . It is
not o u r intention to e n t e r into a d i s c u s s i o n o f the relative m e r i t s o f classification
o f p s y c h i a t r i c d i s e a s e s based on p s y c h o t i c or neurotic c o n c e p t s , e n d o g e n o u s or
e x o g e n o u s t y p e s or q u a n t i t a t i v e or qualitative d~fferences in s y m p t o m a t o l o g y .
T h e s e c o n t r o v e r s i e s h a v e been d i s c u s s e d in detail by o t h e r s . R a t h e r , it is o u r aim
to report the p r e s e n c e or a b s e n c e o f precipitating f a c t o r s on the basis of in-
formation o b t a i n e d from the patients" r e c o r d s o f this r e s e a r c h s a m p l e , and to at-
t e m p t to relate t h e s e factors to o t h e r v a r i a b l e s m e a s u r e d .

M ETH O D
T h r e e o f the investigators examined the c a s e records o f all patients consecutively admitted to the
Iowa S t a t e P s y c h o p a t h i c Hospital starting in the year 1935. R e c o r d s 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 w h o 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)" U S P H S Grants 31H-05911, zldll-11396 and MH-12631.
John Clancy, M . D . : Professor o f Psychiatr)'. Colh'ge o f h4edicine and Psychopathic Hospital.
University o f lowa, Iowa Cio', Iowa; R a y m o n d C r o w e , M.D.: Instructor in Psychiatry. College o f
Medicine and Psychopathic Hospital. Universi O" o f Iowa, Iowa Cio', Iowa; G e o r g e Winokur, M . D . :
Professor and Head o f the Department o f Psrchiatry, Colh,ge o f Medicine and P.Lrehopathic Hos-
pital. University o f Iowa. Iowa City. lowa," J a m e s Morrison, M . D . : ,4.,Mstant Professor o f Psychiatry,
College o f Jledieine and Psychopathic ttospital. UniverMty o f Iowa. Iowa City. Iowa.
© 1973 b), Grune dk Stratton, Inc.
Comprehensive Psychiatry, VoL 14. No. :3 (May/June). 1973 197
 198 CLANCY ET A L

had at least one episode o.f mania). A sufficient number o f bipolar affective disorders (100) and
unipolar affective d i s o r d e r s (225) had b e e n compiled by the middle o f 1940. Between 1935 through
1944 an insufficient n u m b e r o f schizophrenics had been collected so the desired n u m b e r o f 200 was
filled out from admissions in the y e a r 1934.
T h e records were o f an unusually consistent 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 o f laboratory studies and consultations, progress and t r e a t m e n t notes, discharge and
report on final disposition o f patient. T h e .records were s u p p l e m e n t e d by c o m p l e t e social histories
g a t h e r e d by hospital social workers, with particular emphasis on c h a r a c t e r and diseaffes of,ft:mily
members. In addition r e p o r t s from o t h e r hospitals and physicians were nearly always included in the
p a t i e n r s record. A unique feature o f the patient's examination was a rePort o f the stalling c o n f e r e n c e
relative to each patient's diagnosis and t r e a t m e n t program. T h e c o m m e n t s , . d e b a t e , and a r g u m e n t s o f
professors, attending physicians, and residents were all taken down in shorthand by a s t e n o g r a p h e r
and later typed and included in the patient's p e r m a n e n t record. T h e s e reports reflected high quality
and sophistication o f staff.discussions and were very productive o f data for study purposes.
In o r d e 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, o r a relative o r attending physician had ob-
tained information from the patient t h a t the event was indeed considered stressful. (2) If such in-
formation was not present in the chart, then the investigator was p e r m i t t e d to judge w h e t h e r the fac-
tors o r events which preceded the onset o f illness were things "likely'" to be considered stressful.
(3) In addition the stress had to be severe. (4) Dating an event to onset ofillness will almost always in-
volve a degree o f j u d g m e n t . The possibilities o f e r r o r a r e probably reduced when the events are o f re-
cent origin and information is available from multiple sources.' We chose a time limit o f three months
prior to onset o f illness. Only in those cases where t h e r e was definite information in the record to
exceed this l a t t e r limit w e r e such events included. It should also be r e m e m b e r e d that in a c c o r d a n c e
with the diagnostic criteria employed ~ mania had to be present for two weeks, depression for one
month and schizophrenia for six months before being admitted to the study.
Precipitating factors were categorized as psychological, physical, social, combinations o f the afore-
mentioned categories, p o s t p a r t u m and menopausal. T h e determination into which o f the first three
categories a given f a c t o r o r event should be placed was left to the investigator. The n u m b e r o f factors
considered to be a precipitant a r e practically endless but tend to fall into broad groupings, Physical
factors include t r a u m a , surgery, receig'ing or stopping medications with psychoactive properties,
prolonged work. fatigue, particularly under poor living o r climatic conditions, etc. Psychological fac-
tors included those items associated with personal loss o r d,:sappointment, such as b e r e a v e m e n t , de-
p a r t u r e o f family m e m b e r , divorce. Social factors considered to be precipitants included advancing
age, retirement, failing abilities, demotion in status, diminished capacity to engage in previously en-
joyable recreation, poverty, etc. S o m e o f these had m o r e than one dimension and t h e r e f o r e ~'ere
recorded in a combined category. S e p a r a t e class status was also given to the p o s t p a r t u m and
menopausal state.

R ESO 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 i n T a b l e 1.
Of the unipolar affective disorders, 39% were found to have a precipitating event.
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 . 0 5 l e v e l ( X " -- 3 . 9 2 ) . O n l y 1 1 % o f l h e
schizophrenics had a precipitating factor, a significant difference from the bipolar
a f f e c t i v e d i s o r d e r s (/9 < . 0 1 , X'-" = 1 1 . 3 4 ) .
The precipitating fa~:tors were arranged into six classes: psychological,
physical, social, combinations of these, postpartum, and menopausal. Each of
these classes showed significant differences across the three diagnostic groups
with the exception or postpartum. 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
be found among the affective disorders, with unipolar tending to have more than
bipolar illness. Psychological factors were the most frequently found precipi-
 SCHIZOPHRENIA AND ,PRIMARY AFFECTIVE DISORDER 199

Table I
Unipolar AD Bipolar AD Schizophrenia
N = 225 /V = 100 N = 200
(%) (%) {%)

Any precipitant 39 27 11 p < .OO1

Psychological 17 9 4 p < ,001
Physical 5 12 3 p < .O1
Social 5 0 1 p < :01
Psychiatric plus
physical plus social 3 0 0 p < .01
Postpartum 3.5 6 2.5 N.S.
Menopausal 5 0 0.5 p < .01
" A l l p r o b a b i l i t i e s a r e X 2.

tating events. T h e one exception was bipolar illness where physical f a c t o r s

slightly exceeded psychological.
N e x t we e x a m i n e d t h e d a t a to d e t e r m i n e w h e t h e r t h e p r e s e n c e o f a p r e c i p i -
tating event was associated with a ny ot he r characteristics of each of the three
p a t i e n t g r o u p s . T h e c h a r a c t e r i s t i c s s t u d i e d w e r e sex, m a r i t a l s t a t u s , a g e at o n s e t
o f illness, a g e at first a d m i s s i o n , l e n g t h o f illness at i n d e x a d m i s s i o n , p r e v i o u s epi-
sodes, p r e v i o u s a d m i s s i o n , 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 i n s t i t u t i o n , p r e -
m o r b i d p e r s o n a l i t y , suicide a t t e m p t , e d u c a t i o n level, a n d p o s i t i v e f a m i l y h i s t o r y
for m e n t a l illness. T h e r e s u l t s w e r e a l m o s t e n t i r e l y n e g a t i v e . B e i n g f e m a l e
predicted the presence of a precipitating event among unipolar affective disorders
at t h e .01 p r o b a b i l i t y level. H o w e v e r , w h e n p o s t p a r t u m a n d m e n o p a u s e as
p r e c i p i t a n t s w e r e e x c l u d e d , t h e d i f f e r e n c e b e t w e e n m a l e s a n d f e m a l e s w a s no
l o n g e r s i g n i f i c a n t i n d i c a t i n g t h a t it w a s d u e to t h e s e t w o f a c t o r s a l o n e . T h r e e ad-
d i t i o n a l findings w e r e s i g n i f i c a n t a t t h e .05 level. S c h i z o p h r e n i c s with a
p r e c i p i t a n t w e r e m o r e l i k e l y to be single t h a n t h o s e w i t h o u t . F o r a f f e c t i v e
d i s o r d e r , a first e p i s o d e o f illness w a s a s s o c i a t e d with t h e 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 t h e o p p o s i t e w a s t r u e . H o w e v e r , as e a c h o f
the t h r e e p a t i e n t g r o u p s w a s t e s t e d for t2 v a r i a b l e s , t h r e e findings a t t h e .05 level
would not b e i n c o n s i s t e n t w i t h r a n d o m s a m p l i n g e r r o r a n d t h e s e r e s u l t s would
h a v e to be i n t e r p r e t e d w i t h t h i s in m i n d .

DISCUSSION

P r e c i p i t a t i n g e v e n t s w e r e found in a m i h o r i t y o f a n y o f t h e d i a g n o s t i c g r o u p s .
T h e y w e r e p r e s e n t in 35% o f t h e o v e r a l l a f f e c t i v e d i s o r d e r s a n d in 11% o f t h e
s c h i z o p h r e n i c s . T h e o v e r a l l r e s u l t s s u p p o r t a t r e n d 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 f e c t i v e d i s o r d e r and l e a s t f r e q u e n t l y in
s c h i z o p h r e n i a , b i p o l a r a f f e c t i v e d i s o r d e r falling in b e t w e e n . T h e d i f f e r e n c e be-
tween unipolar and bipolar illness d i s a p p e a r e d when they were c o m p a r e d with
p o s t p a r t u m a n d m e n o p a u s e e x c l u d e d . T h e r e f o r e this d i f f e r e n c e is d,Je p . ~ m a r i l y
to t h e s e t w o f a c t o r s .
T a k i n g all alTective d i s o r d e r s as a g r o u p , p r e c i p i t a n t s w e r e fo~,and in 115 c a s e s
o r 35%. T h i s is in line w i t h t h e f i n d i n g s o f H u d g e n s et ai. ~ S t u d y i n g r e c e n t life
e v e n t s in a g r o u p o f h o s p i t a l i z e d a f f e c t i v e d i s o r d e r s d i a g n o s e d b y c r i t e r i a s i m i l a r
to o u r s , t h e y found r e c e n t life e v e n t s w h i c h could h a v e c o n t r i b u t e d to t h e o n s e t o f
t h e i l l n e s s in a f o u r t h o f t h e p a t i e n t s . H o w e v e r , w h e n t h e s e p a t i e n t s w e r e corn-
 200 C L A N C ' i r .ET A L .

p a r e d to a conta-ol g r o u p o f m e d i c a l p a t i e n t s , s i m i l a r life e v e n t s w e r e f o u n d in t h e
s a m e n u m b e r o f c o n t r o l s . T h e y w e r e u n a b l e to find e v i d e n c e t h a t r e c e n t life
e v e n t s w e r e i m p o r t a n t in b r i n g i n g o n t h e d,~sorder. In view o f this, o n e w o u l d e x -
p e c t t h a t as m a n y ,prec.ipi.tants w o u l d b e f o u n d a m o n g the s c h i z o p h r e n i c s . O u r
f i n d i n g o f o n l y t 1% is in s t r i k i n g c o n t r a s t to t h i s e x p e c t a t i o n . T h e r e a s o n for this
d i s c r e p a n c y is n o t c l e a r . It m a y . r e f l e c t t h e views o f t h e p e r s o n s t a k i n g t h e his-
tories t o w a r d t h e illness. T h a t is to say, a p e r s o n w h o r e g a r d s s c h i z o p h r e n i a as a
biological p r o c e s s w o u l d n o t s e a r c h f o r life e v e n t s as a s s i d u o u s l y in s c h i z o p h r e n i a
a s in a f f e c t i v e d i s o r d e r w h i c h is m o r e easily s e e n as a r e a c t i o n to s u c h life e v e n t s .
T h i s is only o n e e x p l a n a t i o n a n d u n d o u b t e d l y o t h e r f a c t o r s c o n t r i b u t e d a s w e l l .
A n a t t e m p t to find a s s o c i a t i o n s b e t w e e n t h e p r e s e n c e o f p r e c i p i t a t i n g f a c t o r s
a n d o t h e r i m p o r t a n t a s p e c t s o f t h e clinical p i c t u r e was a l m o s t e n t i r e l y n e g a t i v e .
The only striking finding w a s t h a t female unipolar depressives w e r e m o r e likely
t h a n m a l e s to h a v e a p r e c i p i t a t i n g e v e n t b e c a u s e o f t h e i n f l u e n c e o f c h i l d b i r t h a n d
menopause.
O u r f i n d i n g s i n d i c a t e t h a t p r e c i p i t a t i n g e v e n t s c a n be f o u n d a m o n g r o u g h l y a
third o f affective d i s o r d e r s d e f i n e d by r e s e a r c h c r i t e r i a a n d 1 1% o f s c h i z o p h r e n i c s
so d e f i n e d . T h e p r e s e n c e o f such e v e n t s , h o w e v e r , s e e m to h a v e little r e l a t i o n s h i p
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 p a t i e n t s o r to t h e clinical p i c t u r e o f t h e
illness.

COMMENT
In this s t u d y w e a r e d e a l i n g 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
primary affective d i s o r d e r or schizophrenia. Excluded from the s a m p l e w e r e
p a t i e n t s w i t h s y m p t o m s t h a t c o u l d b e a t t r i b u t e d to s o m e o t h e r k i n d o f psy-
c h i a t r i c d i s e a s e o r p h y s i c a l illness, and p a t i e n t s w h o s h o w e d a m i x t u r e o f
a f f e c t i v e o r s c h i z o p h r e n i c like s y m p t o m s , w h o a r e o f t e n d i a g n o s e d as s c h i z o -
p h r e n i f o r m o r s c h i z o a f f e c t i v e p s y c h o s i s . E v e n with such a s a m p l e , d e s i g n a t i n g a
f a c t o r as a p r e c i p i t a n t a n d r e l a t i n g it to t h e d e v e l o p m e n t o f t h e illness is o p e n to
a r g u m e n t . 'Statistical e v i d e n c e to s u p p o r t a p a r t i c u l a r p o s i t i o n c a n also be at-
t a c k e d in a v a r i e t y o f w a y s . T h e a u t h o r s t h i n k it useful to e x a m i n e p o p u l a r
t h i n k i n g a b o u t life e v e n t s a n d t h e i r r e l a t i o n s h i p to b e h a v i o r b o t h in h e a l t h a n d in
m e n t a l d i s e a s e . It m a y be t h a t t h e c o n c e p t o f a p r e c i p i t a t i n g o r c a u s a t i v e f a c t o r is
a n e c e s s a r y p a r t o f a c o l l e c t i v e r a t i o n a l s y s t e m o f t h o u g h t w h i c h is a p p l i e d b o t h
to n o r m a l b e h a v i o r a n d b e h a v i o r a s s o c i a t e d with d i s e a s e .
It is g e n e r a l l y a c c e p t e d t h a t life e v e n t s c a u s e c h a n g e s in f e e l i n g a n d m o o d
s t a t e s . T h e s e c h a n g e s a r e r e g a r d e d as p a r t o f n o r m a l f u n c t i o n . In fact, a b s e n c e o f
t h e s e ch~tnges m a y b e r e g a r d e d by s o c i e t y as e v i d e n c e o f illness. T h e - r a n g e a n d
i n t e n s i t y o f t h e s e r e s p o n s e s m a y v a r y g r e a t l y as f o r e x a m p l e in t h e e c s t a s y o f a
religious e x p e r i e n c e o r t h e d e p t h s o f s a d n e s s in a b e r e a v e m e n t a n d y e t be re-
g a r d e d as n o r m a l . N o r h a s an a p p r o p r i a t e d u r a t i o n for s u c h f e e l i n g s t a t e s b e e n
c l e a r l y d e f i n e d . T h e m o u r n i n g p e r i o d , e.g., g i v e s s o m e p u b l i c r e c o g n i t i o n a n d
c o n s i d e r a t i o n for t h e p e r s o n w h o is so b e r e a v e d , b u t it still r e g a r d s t h e p e r s o n as
being w i t h o u t d i s e a s e . T h e b e r e a v e m e r , . t is a sufficient e x p l a n a t i o n in i t s e l f f o r a n y
a l t e r a t i o n in e m o t i o n a l o r m o o d s t a t e . W i t h i n c e r t a i n limits, e x t r e m e s o f t h o u g h t
a n d b e l i e f a r e also a c c e p t e d by s o c i e t y a n d a r e e x e m p l i f i e d in :the u n u s u a l b e l i e f s
h e l d by c e r t a i n r e l i g i o u s sects. T h e s e a r e s o m e t i m e s a t t r i b u t e d to a r e l i g i o u s
e x p e r i e n c e u n d e r g o n e by o n e o r m a n y m e m b e r s o f t h e s e c L 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 D I S O R D E R 201

c o n v e r s i o n s also fall within, t h e c a t e g o r y o f life e v e p t s . E x t r e m e s o f b e h a v i o r a n d

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 c e r t a i n c i r c u m s t a n c e s also p e r m i t t e d b y society.
T h e s e e x a m p l e s point -to t h e a c c e p t a n c e of" an int,ense o r u n u s u a l .life-event as a
sufficient r e a s o n for s o c i e t y to t o l e r a t e c e r t a i n d e v i a t i o n s f r o m usual p a t t e r n s o f
t h i n k i n g , b e h a v i o r , or feeling. T h e y a r e n o t n e c e s s a r i l y classified as.a d i s e a s e be-
:cause t h e y a r e d i f f e r e n t , i n t e n s e , o r p r o l o n g e d , a n d t h e life e v e n t s w h i c h p r e c e d e d
t h e m a r c a p a r t o f t h e i n s t i t u t i o n a l i z e d ex,planation for t h e i r t o l e r a n c e . S i m i l a r
e x t r e m e s o r d e v i a t i o n s a r e also a f e a t u r e o f c e r t a i n d i s e a s e s t a t e s , b u t a dis-
t i n c t i o n o f w h a l is a d i s e a s e a n d w h a t is n o r m a l o n :the basis o f t h e s e f e a t u r e s is
n o t a l w a y s p o s s i b l e . T h e c o n c e p t o f a life e v e n t o r p r e c i p i t a t i n g f a c t o r , r e g a r d l e s s
o f h o w i m p r o b a b l e it m a y be, is also i n v o k e d t o e x p l a i n b e h a v i o r w h i c h is a
s y m p t o m o f d i s e a s e . R e g a r d l e s s o f iss t r u e etiology, " ' s o m e t h i n g h a p p e n e d t o
h i m " is t h e s i m p l e s t e x p l a n a t i o n . T h r o u g h h i s t o r y p r a c t i c a l l y e v e r y c o n c e i v a b l e
s i t u a t i o n or e v e n t h a s b e e n i n v o k e d as an e x p l a n a t i o n f o r a b e r r a t i o n s o f p e o p l e ' s
b e h a v i o r . It is a t r a d i t i o n long i n s t i t u t i o n a l i z e d in society, a n d it is n o t s u r p r i s i n g
t h a t w e c o n t i n u e to s e a r c h for it or, a s a c o r o l l a r y , w e a r e r e l u c t a n t to give u p t h e
search.
T h e i m p o r t a n c e o f a p r e c i p i t a t i n g f a c t o r m a y also be r e l a t e d to t h e v a r i o u s
theories of m e n t a l disease. Siegler and O s m o n d 5 have a r r a n g e d these theories
into m o d e l s t h a t e m b r a c e m e d i c a l , p s y c h o a n a l y t i c , social, m o r a l , family i n t e r a c -
tional, c o n s p i r a t o r i a l , a n d i m p a i r e d a p p r o a c h e s . T h e s e m o d e l s h a v e b e e n s t u d i e d
and c o m p a r e d in a n u m b e r o f d i m e n s i o n s such as e t i o l o g y , d e f i n i t i o n o r d i a g n o s i s ,
t r e a t m e n t , p r o g n o s i s , r i g h t s a n d d u t i e s o f society, etc. T h e u n i q u e c h a r a c t e r o f
t h e m e d i c a l m o d e l is t h a t it g i v e s t h e sick individual a special p r i v i l e g e d "'sick
r o l e " w h i c h r e l i e v e s h i m o f b l a m e f o r his illness, a n d e x c u s e s h i m o f his usual obli-
g a t i o n s for v a r y i n g p e r i o d s o f t i m e . I n t u r n , t h e sick p e r s o n has the o b l i g a t i o n to
try a n d g e t well, a n d to c o o p e r a t e with t h o s e , such as p h y s i c i a n s , w h o m i g h t assist
h i m . 6 U n d e r t h e m e d i c a l m o d e l i t is n o t n e c e s s a r y to knox,," t h e e t i o l o g y o r t h e
c a u s e o f an illness in o r d e r to m a k e a d i a g n o s i s a n d p r o v i d e t r e a t m e n t . But in an
a t t e m p t to p r o v i d e s o m e r a t i o n a l basis for illness in a c c o r d a n c e with s o c i e t y ' s ex-
p e c t a t i o n s , w e as p h y s i c i a n s m a y o f f e r s o m e e x p l a n a t i o n by w a y o f a p r e c i p i t a t i n g
e v e n t o r s i t u a t i o n . T h i s is p a r t i c u l a r l y l i k e l y to o c c u r w h e n t h e e t i o l o g y o f t h e
illness in q u e s t i o n is i n c o m p l e t e o r p o o r l y u n d e r s t o o d .
In e v e r y o t h e r m o d e l o f illness s o m e b o d y o r s o m e t h i n g m u s t a l w a y s b e
b l a m e d 3 In t h e m o r a l m o d e l t h e c a u s e is in t h e i m m o r a l i t y o f t h e p e r s o n . T h e
social m o d e l l o c a t e s t h e t r o u b l e in s o c i e t y ; t h e p a t i e n t is a v i c t i m , a n d t h e c a u s e
o f t h e t r o u b l e lies in o n e o r m a n y o f t h e m u l t i p l e p r o b l e m s t h a t s o c i e t y m a k e s for
t h e individual. T h e p s y c h o a n a l y t i c m o d e l s e e s t h e significant e v e n t in s o m e e r r o r
o r o m i s s i o n by a p a r e n t . T h e f a m i l y i n t e r a c t i o n a l m o d e l s p l a c e s t h e c a u s e o f t h e
t r o u b l e in t h e f a m i l y a n d t h e i d e n t i f i e d p a t i e n t is o n l y e x t e r n a l i z i n g t h r o u g h his
s y m p t o m s an illness w h i c h is i n h e r e n t in t h e f a m i l y itself. T h e c o n s p i r a t o r i a l
m o d e l s is s e e n as a plot in w h i c h s o c i e t y , f a m i l i e s a n d h o s p i t a l s t a f f c o m b i n e to de-
prive t h e p a t i e n t o f his l i b e r t i e s . A s p r e v i o u s l y s t a t e d all o f t h e s e m o d e l s o f illness
i m p l i c a t e s o m e o u t s i d e s o u r c e as c o n t r i b u t i n g to t h e p a t i e n t ' s illness, a n d is a
n e c e s s a r y c o m p o n e n t o f t h e t h e o r y . T h i s d o e s n o t m e a n t h e t h e o r y is c o r r e c t .
P s y c h i a t r i s t s a r e n o t c o n s i s t e n t in t h e i r t h e o r e t i c a l a p p r o a c h to d i s e a s e a n d
t r e a t m e n t a n d t e n d to u s e a n u m b e r o f t h e m o d e l s d e s c r i b e d a b o v e . D e p e n d i n g
upon t h e m o d e l u s e d a n d t h e d i s e a s e in q u e s t i o n t h e n e e d for an e x p l a n a t i o n o r
 20,2 .CLANCY ET A L

causative f a c t o r will vary. T h e p s y c h i a t r i s t .who, e.g., a c c e p t s d e p r e s s i o n as a

disease u n d e r t h e medical m o d e l d o e s not need a c a u s e or e x p l a n a t i o n to m a k e a
diagnosis o r provide t r e a t m e n t . U n d e r a n o t h e r m o d e l some c a u s e o,r e v e n t is
n e c e s s a r y b e f o r e p r o c e e d i n g with t r e a t m e n t on a rational b a s i s . . H e n c e t h e need
for.a p r e c i p i t a t i n g o r c a u s a t i v e f a c t o r is sustained, at least a t a theore'tical level.
P r e c i p i t a t i n g f a c t o r s seem to b e .of tess c o n c e r n in c h r o n i c illness.
S c h i z o p h r e n i a is a c h r o n i c disease and a p r o p o r t i o n o f d e p r e s s i v e s a r e subject to
r e c u r r e n t a t t a c k s of illness. T h e p e r s o n who is c h r o n i c a l l y ill m a y b e t h e un-
f o r t u n a t e b e n e f i c i a r y o f the i m p a i r e d role. T h e i m p a i r e d p e r s o n is seen as
"'different," h e m a y be blind, deaf, p a r a l y z e d or m e n t a l l y ill, but o n c e i m p a i r e d it
does n o t m a t t e r how he got his i m p a i r m e n t . T h e i m p a i r e d person is e x p e c t e d to
b e h a v e as n o r m a l as possible and not to fuss a b o u t his h a n d i c a p . T r e a t m e n t , with
a goal of c u r e is not in question and rehab:.litation has a m o r e m o d e s t goal o f res-
t o r a t i o n o f function but with c o n t i n u a n c e of the h a n d i c a p . P e r ris u r e p o r t e d
p r e c i p i t a t i n g .factors o c c u r r i n g within t h r e e m o n t h s :in a p r o p o r t i o n of s u b j e c t s
before .the first episode o f b i p o l a r o r u n i p o l ~ r d e p r e s s i v e illness. R e l a p s e s ,
h o w e v e r , s e e m e d to o c c u r i n d e p e n d e n t l y from p r e c i p i t a t i n g factors. This m a y
m e a n t h a t p r e c i p i t a t i n g f a c t o r s a r e less influential in c h r o n i c illness, but it could
also m e a n t h a t t h e y a r e not n e c e s s a r y and a r e not sought for u n d e r the i m p a i r e d
model.

SUMMARY

A s a m p l e of 200 schizophrenics and 225 p r i m a r y affective d i s o r d e r s was se-

lected on the basis o f rigid d i a g n o s t i c criteria, from hospital records. An a t t e m p t
was m a d e to find a s s o c i a t i o n s b e t w e e n p r e c i p i t a t i n g factors, d i a g n o s t i c g r o u p s ,
and c e r t a i n p a t i e n t and clinical c h a r a c t e r i s t i c s . O u r findings i n d i c a t e t h a t precipi-
tating e v e n t s can be found in 35% of p r i m a r y affective d i s o r d e r s and 11% o f
schizophrenics. T h e r e is a t r e n d for p r e c i p i t a n t s to be seen m o s t f r e q u e n t l y in
u n i p o l a r affective d i s o r d e r and least f r e q u e n t l y in schizophrenia, b i p o l a r affective
d i s o r d e r s falling in between. P r e c i p i t a t i n g events, however, seem to have little
relationship to personal o r social c h a r a c t e r i s t i c s o f p a t i e n t s o.r to the clinical pic-
t u r e o f the diseases studied.

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