Clinical Psychology Review 25 2005 1008 1027 Life events in bipolar disorder Towards more specific models Sheri L Johnson University of Miami United States Received 11 May 2004 received in revised form 11 May 2005 accepted 13 June 2005 Abstract This 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 are defined 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 many depressions are unrelated to negative life events and appear to be triggered by other variables The strongest evidence suggests that negative life events do not trigger mania except perhaps in certain contexts Retrospective findings for schedule disrupting life events as a trigger for manic symptoms await further assessment within a longitudinal study Life events involving goal attainment do appear to trigger manic symptoms Overall it is time to differentiate among specific types of life events as these different forms of events point towards mechanisms linking stressors with symptom expression These mechanisms provide clues into ways to integrate the social environment with biological vulnerability see Monroe S M Johnson S L 1990 The dimensions of life stress 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 Behavioral 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 of research has made it abundantly clear that psychosocial variables shape outcomes of this disorder Much of this psychosocial research has focused on whether life events predict the timing and severity of symptoms within this disorder E mail address Sjohnson miami edu 0272 7358 see front matter D 2005 Elsevier Ltd All rights reserved doi 10 1016 j cpr 2005 06 004 S L Johnson Clinical Psychology Review 25 2005 1008 1027 1009 This paper reviews the evidence that life events are related to symptom expression within bipolar disorder 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 life events What types of life events influence symptoms Given the growing number of studies available on these issues this review will focus on those studies with the most rigorous methodologies To set the stage for this endeavor it is important to first review the major methodological issues in research on life events and bipolar disorder including issues related to design measurement and sampling 1 Design issues in studies of life events and bipolar disorder Researchers have used many different designs in this field both cross sectional and longitudinal There are genuine difficulties in interpreting the results of cross sectional studies Consider that some people with bipolar disorder experience elevated levels of life stress even during asymptomatic periods High rates 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 should not be hard to document high levels of stress at any time in the lives of people with bipolar disorder compared to people with no mental illness cross sectional findings could overestimate the role of life events as triggers of symptoms in bipolar disorder because these designs do not provide information about whether life events are specifically elevated before episodes of bipolar disorder as compared to other times in the lives of people with bipolar disorder Between group comparisons then do not address a key question are episodes preceded by increases in stress That is researchers can assess whether life events are more common before episodes than they are after episodes This contrast between time periods provides tighter control than the between group comparisons described above Others have considered a slightly more powerful question When a person with bipolar disorder experiences 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 become depressed due to medication issues social isolation hopelessness about the disorder or any number of other problems As a result negative life events per se may not be a common explanation for bipolar depression Nonetheless it could still be the case that when a negative life event occurs a person with bipolar disorder could be at high risk for depression In a psychopathology with such multifactorial etiology it is important to distinguish two orthogonal questions 1 Are most episodes explained by life events and 2 Do life events predict increases in symptoms Because there are many potential confounds in life stress studies within subject comparisons are important to evaluate these questions 2 Measurement issues in studies of life events and bipolar disorder Unfortunately many of the measures in the life stress field can be criticized on psychometric and conceptual grounds see Johnson Roberts 1995 Measurement error is not random Bipolar symptoms are distressing and people are highly motivated to find evidence that their episodes were triggered and thereby will be somewhat predictable in the future In the search for explanations people 1010 S L Johnson Clinical Psychology Review 25 2005 1008 1027 may be reassured if they can identify life events in the months before episode onset This potential for systematic error mandates careful measurement Several strategies have been developed to control for errors and biases in the identification dating and evaluation of life events In gathering life events data a first goal is to ensure that all participants think about a full range of life events rather than reporting just those events they construe as meaningful to their disorder That is assuming that