environmental stress and psychiatric disorder

STRESS MEDICINE, VOL. 2: 291-299 (1986)

STRESS IN THE COMMUNITY

ENVIRONMENTAL STRESS AND PSYCHIATRIC DISORDER

HUGH FREEMAN, MA, MSc, BM, FRCPysch Hope Hospital, Salford M6 8HD, UK

SUMMARY It has long been believed that environmental stress is an aetiological factor in psychiatric disorder, but the scientific investigation of this subject is extremely difficult, mainly due to the complexity of the intervening processes. Forms of stress which have been examined include noise, rapid social change, migration and crowding. The role of social stress remains problematic.

KEY worms-Stress, stressor, environment, migration, psychiatric disorder.

The view that external stress is aetiologically related to psychiatric disorder has a long history, but Ray’ points out that in its modern form the stress model was first adumbrated in Bucknill and Tuke’s Manual of Psychological Medicine, published in 1858. These authors quoted evidence that the predisposition to insanity varied not just with. heredity but also with sex, age, marital status, occupation and (most relevant here) town or country residence. The corollary of this environmental or ‘moral’ view was that insanity was treatable through manipulation of the environment, for example removal to an asylum and withdrawal from social responsibilities. Insanity was seen as having a moral or volitional component, over and above the physical, which meant that it was not simply a physical disease and that it needed to be. managed in the environment of special institutions.

URBANIZATION

Later in the nineteenth century, it became the conventional wisdom in industrializing countries that greater urbanization, with the ‘mental over- exertion’ this was believed to cause, was respqn- sible for higher rates of mental illness-thought to be indicated by the growing populations of 0748-8386/86/040291-09$05.00 @ 1986 by John Wiley & Sons, Ltd.

asylums. However, this view was rejected by Kraepelin after he had travelled to Singapore and examined the population of the mental hospital there, made up from various Asian races: he observed a remarkable homogeneity of symptoms and history, both among these patients and compared with Europeans. His conclusion was that race, climate, food and any other general circumstances of life such as urbanization should be excluded as causes of psychosis.2 In 1911, Daw- son3 reported that the hospitalization rate for mental illness in Ireland was 5.52 per thousand, compared with 3.61 for England and Wales; however, the more industrial province of Ulster had a rate of only 4.2, whereas the eight Irish counties with the highest rates were all agricultural and also had high rates of pauperism. This general picture still holds good, though explanations for it vary g r e a t l ~ . ~

In fact, there is no agreement yet as to whether or not urbanhural differentials exist for psychiatric m ~ r b i d i t y . ~ In Murphy’s6 view, such uncertainty should not be taken to mean that the hypothesis of additional social stress in cities is wrong, but rather that the usual urban-rural dichotomy does not represent it adequately. This is because each large urban or rural area is too diverse to have the same impact on all its inhabi- tants, whereas small population units may be

Received April I986

292 HUGH FREEMAN

more specific in terms of the pattern of interpersonal effects within them. Further method- ological problems result from the fact that ‘urban’ and ‘rural’ have very different meanings in different contexts-for instance a European city of 100,000 people compared with Mexico City’s 13 million.

Though stress has generally be regarded as primarily an urban phenomenon, related to ‘alienation’ or ‘anomie’, Keller and Murray’ point out that rural people have always been stressed by their environment; they are ultimately dependent on the weather for their success or failure and keenly feel their lack of control over it. Quite apart from climatic effects, rural isolation may lead to loneliness, depression, a sense of help- lessness and failure of interpersonal skills. These authors add that further emotional stress may result from the challenges which modern com- munications bring to rural values and lifestyles, particularly causing conflict in the young, and that ‘rural life is complicated by many significant social, economic, and environmental problems that take a heavy toll on those who live there’. Therefore, it would be simplistic and misleading to regard environmental stress as particularly characteristic of either urban or rural life per se. One of the main difficulties of theories which regard the transition from rural to urban life as inherently stressful is not so much an incorrect view of city life as ‘a mistaken and romanticized image of what village, rural, or tribal life is typ- ically like’.8

THE STRESS MODEL

The concept of stress has emerged as probably the most useful general explanation of the mediating processes between the environment and individual reactions; however, these processes are undoubtedly most complex, and it is difficult to construct effective research designs to investigate them. Two models have dominated the field up to now.” The first is the physiological, derived from Selye, which implies both a homeostatic concept of bodily function and the existence of negative affects from the processes of coping with stress, which act independently of the impact of the stressor itself. Secondly, there is the psychological model, which emphasizes cognitive interpretation of environmental conditions, influenced by characteristics both of the indi-

vidual and of the context. Evans states that it is not clear which model is more crucial in deter- mining human reactions: though biological approaches tend to overemphasize physical pathogenic outcomes, psychological effects, for example on mood or interpersonal relationships, are also very important, both as outcome measures in themselves and through their affecting the susceptibility of the host organism to disease.

Environment In a broad sense, practically every kind of stress

can be said to be environmentally derived, i.e. resulting from an imbalance between the demands of the environment and the individual’s ability to adjust to them; assuming that an organism strives to maintain a state of homeostasis with the demands of his natural, social and cultural environments, there is then a perceived threat.“’ The stress reaction, which may take the form of anxiety, defensiveness, avoidance behaviour, etc provokes the individual to reduce the dis- equilibrium to the point where the environmental field is seen as ‘problem-free’. Whether a particular situation is conducive to stress depends on the individual’s emotional stability or vul- nerability and on his personality structure, as well as on the importance (salience) and controllability (congruence) of the environmental setting in which the stressors occur.” Although an individual may successfully maintain normal performance through adaptation, it should not be assumed that the stresses operating on him have no negative effects, since the adaptive efforts themselves may well be harmful to him in the long run.y Unless the various kinds of changes in environmental conditions which are generally conceptualized as ‘stressful’ share some common mechanism, however, the whole construct of stress will not remain credible. This has still to be rigorously defined in a scientific way, but phenomena which on commonsense grounds may be presumed to be reactions to it can be observed and sometimes measured.

Evans also points out that the processes which make certain environmental conditions stressful can be seen in various different terms: first, an arousal model proposes that they primarily affect the reticular activating system, and that stress will result if arousal levels move outside an optimum range; secondly an overload model assumes that a simple excess of environmental stimuli has

ENVIRONMENTAL STRESS 293

harmful effects; thirdly, a systems model sees stress as resulting from individual needs being thwarted by environmental conditions.

Though it would be convenient if each separate stressor could be aetiologically associated with a specific pathological effect, present knowledge indicates that the phenomenon is largely non- specific in both its determinants and its consequences. Rabkin and StueningI2 conceptualized stress itself as the joint product of socially structured situations and environmental factors; it is thus a general concept, describing the organism’s reactions to environmental demands, and its util- ity lies in identifying productive lines of research into the aetiology of disease which encompass external events influencing individuals and populations. The aetiological model of the onset of illness is generally associated with certain poten- tial factors; these include ‘stressful environmental conditions, perception by the individual that such conditions are stressful, the relative ability to cope with or adjust to these conditions, genetic predisposition to disease, and the presence of a disease agent’. Animal data show that a wide variety of pathological conditions emerge following changes in the social milieu, and in humans also variations in group relationships could be expected to enhance susceptibility to disease in general rather than having a specific aetiological roIe.I3 The fact that certain regions of the USA have a higher death rate than the national average from all causes may possibly confirm this view.

SOCIAL CHANGE

Chronic stress is accepted as being engendered usually not by a single traumatic event but rather by a series, any one of which may be temporarily annoying but which together combine to induce a state of morbid anxiety or depression. Therefore, potentially stressful factors which endure over time and from which there is little possibility of escape are likely to be relevant to psychiatric morbidity; amongst these, environmental conditions may be an incessant source of irritation, as well as being often difficult to avoid and therefore less amenable to improvement.

Noise stress One example of these conditions is noise.I4

Physiological changes produced by noise consist of non-specific responses often associated with stress reactions; these responses include changes in electrodermal activity, cardiovascular activity and hormone secretions, which can affect the respiratory and digestive systems. However, existing experimental studies have involved only short-term exposure to relatively high sound levels, so that extrapolation to the effects of sus- tained environmental noise in vivo must be ten- tative. l5

People’s reaction to the intrusion of unwanted noise into their private lifespace is described as ‘annoyance’; those who report a high level of it show more symptoms of all kinds, consume more psychotropic drugs and seek more medical and psychiatric help. In a small minority of apparently normal people, habituation of the physiological response to noise consistently fails to occur;16 this phenomenon has not yet been systematically investigated but a connection with annoyance would seem logical. From a survey of the literature, Monahan and Vaux” concluded that, ‘Under certain circumstances, noise may decrease attraction and affiliative behaviour between people, increase aggressive behaviour, decrease the probability that people will come to one another’s aid, and contribute to tension-related illness’. There is no evidence of a connection between noise and severe psychiatric disorder, but strong indications that it can be an aetiological factor in neurotic reactions, particularly in those people who have a constitutional sensitivity to it.

Social change Another example is rapid social change, which

has often been considered a form of social stress, though RueschIX believed that ‘tolerance limits . . . show great individual variation, and what causative role social change plays in the aetiology of mental disease has not yet been clearly established’. Selye19 proposed that the phenomenon of change itself, beyond the capacities of the organism to adapt-and irrespective of the results of the change-is the critical precipitant of stress- related pathology, whether physical or psychiatric. However, Brenner’s2” view was that del- eterious life changes should be regarded as more harmful than others because they are capable of producing stresses, which in turn lead to other life changes and further stresses (‘acceleration of

294 HUGH FREEMAN

stress'). He concluded that all abrupt economic changes, regardless of direction, are stress-provoking, but that undesirable changes such as unemployment and income loss must be the more pathogenic. This appeared to be consistent with Selye's view that extremely high stimulation has an overall stressful effect, though the whole issue remains a controversial one. Cassel13 suggested that those involved in rapid social change become unfamiliar with the aims and expectations of their society, find that their actions are unlikely to lead to anticipated consequences and thus experience stress, which leads to neuroendocrine disturbance and so to increased susceptibility to disease.

Brown ef a1.2' concluded from their comparative studies of an inner London district and a Hebridean island that the main psychiatric impact of the changes of industrialization and urbanization has been in causing a very high rate of depression among working-class city women. Middle-class women there have largely avoided this, though they experience more depression than women in a traditionally structured community. On the island, there was a higher rate of depression among certain groups of women who had moved further from a traditional way of life and this seemed to be linked to the same kind of provoking agents that were found in the inner city, particularly among working-class women.22 However, a simple urban-rural dichotomy did not give an accurate picture of the differing rates of depression within the two populations and Goldberg and Huxleyz3 believe that the factors which produce such differences need not be social or environmental but could equally be genetic or of selective migration.

The possible effects of rapid social change were also investigated in a longitudinal study of drink- ing habits in two communities of the Shetland Islands since the arrival of the oil industry there.24 Increases in mean alcohol consumption were found to be twice as large in an area directly affected by the oil developments as in a central area, where such activities were excluded; however, in both communities, increases in drink- ing were largely concentrated among those aged under 30, who were presumably more susceptible to the effects of the social change. In Australia, B ~ r v i l l e ~ ~ reported that psychiatric impairment rates were substantially higher in isolated new mining towns than in more diversified and settled communities.

Athens earthquake A third, and dramatic, illustration of the effects

of environmental stress on physical and mental health came from the Athens earthquake of 1981 .26 Though several lines of evidence link fatal heart attacks, and particularly sudden deaths, with acute psychological stress, up to then there had been no adequately controlled epi- demiological study to demonstrate this association in a human population. However, a very large number of people with adequate health and registration services were suddenly and sim- ultaneously exposed here to events that invoked the danger of death or serious injury. Earth- quake-related stress was found to have increased the short-term probabilities of a fatal cardiac event by about 50 per cent and of death from atherosclerotic heart disease by about 100 per cent. The peaking of the excess of cardiac deaths during the third, rather than the first day after the major earthquake was thought to be related to lesser quakes having occurred o n the second and third days; the symbolic danger of these may have generated stress as effectively as the real danger through conditioned reflex pathways having become established. The facts that deaths from quake-related cardiac events were more common among men than women and among subjects aged 69 or less than among the elderly were also thought to confirm this general interpretation of the findings.

MIGRATION

The relationship of stress to residential mobility has attracted much a t t en t i~n .~ ' In many cases, it is possible that the stresses encountered in the new environment merely trigger off psychiatric disorder in those already susceptible through genetic, personality or social factors.2x However, i t will also be relevant whether the migration was voluntary or unwilling; in Australia, for instance, wartime and political refugees from Eastern Europe have been particularly vulnerable to many forms of severe psychiatric disorder.2" For many migrants, the stresses generated by actually settling in the new environment appear to be capable themselves of precipitating psychiatric disorders; such stresses are greatest for those migrants who differ most markedly from the host population in terms of colour, language and religion. These stressful experiences generally dis-


sipate after a few years, so that lower levels of psychiatric illness are then recorded.”’ However, for some groups, the problems persist: in Aust- ralia, for instance, this was found among middle- aged housewives from southern European countries who remained housebound and did not learn English (though their husbands and children did) and among professional people whose quali- fications had not been recognized in Australia, so that their social status greatly diminished.3’

Miller32 used a stress model to analyse the psychiatric implications of geographical mobility in terms of four main points: first, antecedent events; secondly, separation, which is unlikely to have serious psychosocial sequelae if the migration is unforced and if the lost social organ- ization can be replaced; thirdly, the process of moving, which is relatively well tolerated intra- nationally in most cases but may be associated with greater stress transnationally; and fourthly, reestablishment in the new environment, when the degree of stress depends on many factors- in the individual, his family and in the host community. There are two main explanatory hypotheses for any relationship between psychiatric morbidity and mobility behaviour: these are first, social causation (that migration is more stressful than non-migration), and secondly, social selec- tion (that the mentally i l l migrate in relatively greater numbers than the non-mentally i l l ) . Miller concluded that both these hypotheses were over- simplistic, and that any relationship between the phenomena concerned was very complex.

Urban relocation So far as forced intra-urban relocation is con-

cerned, it seems reasonable to conclude that the residents of older, rented, inner city housing will be particularly affected by the stressful pre- cipitants which generate these moves, for example, decay of family neighbourhoods, changed social or racial composition of the population or major changes in land use. In the USA, local inner-city moves have been found to be relatively more frequent among blacks than whites in these areas, and may be due to largely vain attempts to find satisfactory housing and surroundings within the predominantly poor quality stock in the ghetto.33 The stresses induced by such residential constraints were found to be particularly marked among those blacks who were ambitious to improve their educational and

socioeconomic status. Levy and row it^^^ recorded higher admission rates to mental hospitals among blacks who had managed to move upwards socially and outwards spatially from the ghetto than among those left behind; one possible explanation of this difference is that even greater levels of stress may have been experienced after the move, perhaps because expectations were not realized by it.

A study of a large new residential development (Thamesmead, London) by HigginsXs concluded that adverse features of the physical and social environment were responsible for a good deal of stress in its early years but that the direct effect on the health of individuals was difficult to judge. In addition to emotional arousal and physiological changes, stress may result in the adoption of various behaviours. including outward migration, political action or protest and seeking help, particularly from a doctor. The latter may be specifically for social reasons (eg to gain priority for rehousing) or because the subject feels ill; in the latter case, the illness may present as a physical disorder or be seen by both patient and doctor as a psychological disturbance. It seems reasonable to assume that the act of seeking a doctor’s help is an indication that an individual has reached a certain threshold of distress, but this threshold varies both between individuals and in the same person under different conditions.

Out of 747 families who moved into Thames- mead during the first 2 years. Higgins recorded 75 at the minimum where at least one individual had an emotional disturbance related to environmental stress, but the true figure was almost cer- tainly much higher. Out of 243 households in a sample studied, 70 moved out within 3 years, and amongst these there were twice as many complaints about life in the community as among the families that remained. In most cases, stress was due less to features of the physical environment than to frustration associated with inability to obtain any change; the stress most commonly reported was high rents, but there were also complaints about disturbing neighbours, quality of the housing, noise, etc.

CROWDING AND DENSITY

There is commonly confusion between these two terms, but whereas ‘density’ is purely a math- ematical ratio, indicating the number of persons

296 HUGH FREEMAN

present in a unit of area, 'crowding' relates to the number of persons per dwelling unit and is a concept strongly influenced by psychological and cultural factors.36 While it may be assumed that crowding occurs when the personal space of the individual is felt to be invaded (a very relative experience), the nature of that stress has yet to be determined. Gove et al.37 have proposed a general model in which the subjective experience of crowding (excess demands and lack of privacy) acts as an intervening variable between a measure of crowding (eg persons per room) and dependent variables (certain pathological states and behaviours). Stress will occur, for instance, when an antagonistic encounter takes place and the restric- tion on space prevents a retreat of either party.

S t o k o l ~ ~ ~ divided crowding experiences along two dimensions: first, into personal or neutral (where the stres's is seen in the latter as an inevi- table consequence of environmental restraints), and secondly, into those taking place in the primary environment (home, place of work) or in the secondary environment (train, theatre, street). Crowding would be expected to exacer- bate stress in the primary environment, while high density or large numbers would possibly do so in the secondary, though such stresses would have different effects on different individuals. In fact, both social factors and the huge variations in personality, coping skills, etc between individuals make the attempt to relate such specified stress to specific effects in individuals very questionable. It also has to be remembered that the stresses of isolation can be as great as those of crowding."'

Casse14". 4 1 proposed that, in some societies at least, an association between crowding and physical stress may derive from the particular kind of stress that arises from accompanying dis- ordered social relationships. However, such adverse effects might be confined to the periods following change, such as migration, with adaptation to these conditions once people had become accustomed to them.

Miller32 proposed a model in which, for each individual, there is an optimum range of population density beyond which-in either direction-he will begin to experience stress. This range would vary according to such factors as characteristics of that individual, cultural characteristics of his group and sociological characteristics of his environment. The disruptive effects of extreme density would be expected to occur within a narrower range for some psy-

chological-behavioural dimensions (eg affective interpersonal behaviour) than for others (eg task performance). Similarly, for a given individual or subpopulation, the range of non-stressful den- sities would be more restrictive than for a large population. If an individual or a subpopulation moved to a point along the density dimension which was outside their usual experience stress would result, but would be relieved over time by adaptation. However, operationalization of this model presents very many problems, and Miller concluded that the exact relationship between stress and feeling crowded or between feeling crowded and pathological behaviour remains unresolved.

PERSONALITY AND CULTURE

It has been pointed out above that the results of environmental stress on mental health will depend partly on the individual personality, but Graves and Graves42 state that the two dominant research traditions in the study of stress and illness have been concerned on the one hand with the impact of the external environment and on the other hand with intrapsychic differences which predispose people to react to the world in a more or less stressful way. There has been almost no interaction between these two approaches, yet the subject seems to call for a joint social-psychological perspective.

To try to achieve this, they compared native- born New Zealanders with Polynesian immigrants living in the same working-class neighbourhoods in Auckland; it was assumed that the immigrants would suffer from relatively many more life changes, situational stresses and daily problems when adjusting to their new urban home. It was also hypothesized that Polynesians would differ from those of European stock in exhibiting fewer type A personality attributes, on the assumption that type A behaviour may reflect an effort to maintain personal control over life events and their outcomes. Both type A characteristics and situational stressors were anticipated to be associated with higher rates of poor health and to be alternative paths to health problems within these two populations. Empirical investigation of these questions depended on three measures: of the subjects' current state of health, of their daily stressful circumstances and of personality attributes affecting their response to external stres-


sors. The findings were limited by the depen- dence of these measures on retrospective self- report data, but a consistent pattern of relationships across measures emerged.

Against expectation, the immigrants appeared overall to be making a better adaptation to urban life than the controls, reporting fewer health problems, though there was some difference (cul- turally explained) between Samoans and Cook Islanders. Also against expectation, the immigrants did not report greater exposure to objec- tive situational stressors, possibly because a larger proportion were more type B than type A in character, with a relaxed approach to life. Thirdly, it had been anticipated that the immigrants' use of a wide circle of relatives and co- ethnics would be an important factor in reducing symptoms of adaptive stress in the city, but this view of social support was not confirmed, perhaps because of the cultural pressures to provide reci- procities for help received. However, it may be relevant that multidimensional relationships such as are found with many migrants are more satisfy- ing and stress-buffering than unidimensional.43 One possibility not considered by Graves and Graves is that selective migration resulted in the immigrants being of a more resilient nature than their native-born neighbours.

SOCIAL STRESS

The concept of social stress assumes that such phenomena as stigmatization, effects of poverty, role disturbance (eg one-parent families) and high parity are of aetiological significance in psychiatric disorders, but there is little agreement in the literature as to which factors should be included, and in spite of statistical associations in some reports this significance remains to be established. Most studies which have attempted to investigate social causes of psychiatric disorder have used social stress as a frame of reference; Murphy" regarded this as including social forces or events which threaten psychological well-being through the failure to satisfy needs (though 'needs' clearly represents a very relative concept). Dohrenwend4' claimed highly consistent relationships between the estimated prevalence of various psychiatric disorders and three sociocultural factors-sex, urban or rural residence and social class-but differences between overall urban and rural psychiatric morbidity are now uncertain.s

It has been claimed by Warner-' that the material conditions of life mould the course and outcome of schizophrenic illness and, with other factors, influence its prevalence. He suggests that social stress and social drift may operate together to account for the social class gradient in the prevalence of schizophrenia in urban-industrial areas and that residents of large cities are more exposed than those of rural areas to fluctuations in the economy, with resulting psychological distress; furthermore, the outcome from schizophrenia is relatively better in non-industrialized societies, while sufferers in industrialized societies have restricted social networks and their families become estranged from society. There is con- siderable disagreement, however, as to the extent of variations in the prevalence of schizophrenia between societies at different stages of economic development and urbanization. TorreyJ5 main- tains that the condition is rare in societies which have not been exposed to Western civilization, but the matter may not be resolved until much more reliable comparative data on incidence are available.

CONCLUSION

Direct cause-and-effect relationships are extremely unlikely to be found between specific features of the environment and specific forms of psychiatric morbidity, due to the enormous complexity of the intervening processes.26 How- ever, our understanding of the subject could be greatly enhanced by more sophisticated research, particularly over longer time periods and on a multidisciplinary basis. Up to now, the subject has not figured prominently on the research agenda of any scientific discipline.

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