Life events in bipolar disorder: Towards more specific modelsDesign issues in studies of life events and bipolar disorderMeasurement issues in studies of life events and bipolar disorderSample definition in studies of life events and bipolar disorderReview of life event findings in bipolar disorderStudies that do not distinguish polarity of symptomsPolarity-specific effectsLife events and depressionAre negative life events as common before bipolar depression as before unipolar depression?Are life events more common before episodes of depression than they are before other life periods?Do life events predict increases in depressive symptoms?Summary of life events and depressionLife events and maniaNegative life eventsAre negative life events common before manic episodes?Do negative life events predict increases in manic symptoms?Summary of negative life events and maniaSchedule-disrupting life eventsGoal attainment life eventsConceptual IntegrationAcknowledgementsReferencesLife events in bipolar disorder: Towards more specific modelsSheri L. JohnsonUniversity of Miami, United StatesReceived 11 May 2004; received in revised form 11 May 2005; accepted 13 June 2005AbstractThis article reviews the evidence concerning life events as a predictor of symptoms within bipolar disorder.First, key methodological issues in this area are described, and criteria used for including studies in this review aredefined. Then findings that negative life events predict worse outcomes within bipolar disorder are reviewed.Beyond general studies on relapse, it is important to differentiate predictors of depression from predictors of mania.When severe negative life events occur, they appear to trigger increases in bipolar depression. Nonetheless, manydepressions are unrelated to negative life events and appear to be triggered by other variables. The strongestevidence suggests that negative life events do not trigger mania, except perhaps in certain contexts. Retros pectivefindings for schedule-disrupt ing life events as a trigger for manic symptoms await further assessment within alongitudinal study. Life events involving goal attainment do appear to trigger manic symptoms. Overall, it is timeto differentiate among specific types of life events, as these different forms of events point towards mechanismslinking stressors with symptom expression. These mechanisms provide clues into ways to integrate the socialenvironment with biological vulnerability (see [Monroe, S. M., & Johnson, S. L. (1990). The dimensions of lifestress and the specificity of disorder. Journal of Applied Social Psychology, 20, 167–1694; Harris, T. O. (1991).Life stress and illness: The question of specificity. Annals of Beh avioral Medicine, 13, 211–219]).D 2005 Elsevier Ltd. All rights reserved.Bipolar disorder is clearly a biological disorder. Nonetheless, over the past 15 years, a wealth ofresearch has made it abundantly clear that psychosocial variables shape outcomes of this disorder. Muchof this psychosocial research has focused on whether life events predict the timing and severity ofsymptoms within this disorder.0272-7358/$ - see front matter D 2005 Elsevier Ltd. All rights reserved.doi:10.1016/j.cpr.2005.06.004E-mail address: [email protected] Psychology Review 25 (2005) 1008– 1027This paper reviews the evidence that life events are related to symptom expression within bipolardisorder. This basic question has challenged researchers for over 20 years. Given the growing literature,this paper focus on addressing two more specific questions. Which types of symptoms are related to lifeevents? What types of life events influence symptoms? Given the growing number of studies availableon these issues, this review will focus on those studies with the most rigorous methodologies. To set thestage for this endeavor, it is important to first review the major methodological issues in research on lifeevents and bipolar disorder, including issues related to design, measurement, and sampling.1. Design issues in studies of life events and bipolar disorderResearchers have used many different designs in this field, both cross-sectional and longitudinal. Thereare genuine difficulties in interpreting the results of cross-sectional studies. Consider that some peoplewith bipolar disorder experience elevated levels of life stress even during asymptomatic periods. Highrates of divorce (Kessler, Walters, & Forthofer, 1998), unemployment (Goldberg, Harrow, & Grossman,1995), victimization (Goodman et al., 2001), and stigmatization (Hayward, Wong, Bright, & Lam, 2002;Torrey, 2002) are well-documented in this population. Given these sad consequences of disorder, it shouldnot be hard to document high levels of stress at any time in the lives of people with bipolar disordercompared to people with no mental illness—cross-sectional findings could overestimate the role of lifeevents as triggers of symptoms in bipolar disorder, because these designs do not provide information aboutwhether life events are specifically elevated before episodes of bipolar disorder as compared to other timesin the lives of people with bipolar disorder.Between-group comparisons, then, do not address a key question—are episodes preceded byincreases in stress? That is, researchers can assess whether life events are more common before episodesthan they are after episodes. This contrast between time periods provides tighter control than thebetween-group comparisons described above.Others have considered a slightly more powerful question. When a person with bipolar disorderexperiences a severe stressor, is that person likely to experience an increase in symptoms? At first glance,these last two questions may appear similar, but they are not. A person with bipolar disorder could becomedepressed due to medication issues, social isolation, hopelessness about the disorder, or any number ofother problems. As a result, negative life events per se may not be a common explanation for bipolardepression. Nonetheless, it could still be the case that when a negative life event occurs, a person withbipolar disorder could be at high risk for depression. In a psychopathology with such multifactorialetiology, it is important to distinguish two orthogonal questions: (1) Are most episodes explained by lifeevents? and (2) Do life events predict increases in symptoms? Because there are many potentialconfounds in life stress studies, within-subject comparisons are important to evaluate these