Parenting and schizophrenia: an Australian study of expressed emotion

Parents of 66 schizophrenic Sydney patients were interviewed using the abbreviated Camberwell Family Interview (CFI). Using pre-established criteria, 71% of the mothers, 58% of the fathers and 74% of the households were categorised as being of high expressed emotion (EE) status. Comparison is made with published data on the CFI and on EE categorisation for similar groups studied in England, the United States and India. The Sydney families were described as 'vocal, ambitious and aggressive', and EE scale scores more resembled the Los Angeles families than the British families originally studied. A number of factors influencing high EE categorisation (e.g., family intactness, socio-demographic variables) are noted.     

A comparison of psychiatric symptoms between Anglo-Americans and Mexican-Americans with schizophrenia

Culture is widely thought to influence the form, content, and extent of symptoms experienced and expressed by the mentally ill. However, little is known about how specific cultural groups differ in their symptomatic presentation of mental illness. Using data derived from the Present State Exam, the current study compared 63 Anglo-American and 53 Mexican-American patients with schizophrenia on ten psychiatric symptoms. A series of logistic regressions offered several interesting findings. For instance, as hypothesized, Mexican-American patients were more likely to report physical symptoms than their Anglo-American counterparts. Also in line with expectations, Anglo-American patients reported experiencing a greater frequency of several psychiatric symptoms such as persecutory delusions, nervous tension, and blunted affect. Results from this study suggest that the presentation of even a very biologically determined disorder such as schizophrenia can be shaped by sociocultural factors. Specific aspects of Anglo-American and Latino cultures that may influence symptom patterns in patients suffering from schizophrenia are discussed.     

Determinants of expressed emotion in mothers of schizophrenia patients

Our objectives were to determine the extent to which symptoms in the schizophrenia patient and personality in the mother lead to a sense of subjective burden in the mother, and to explain variance in two components of Expressed Emotion. Data on symptom severity (PANSS), mothers' personality (NEO-PI), subjective burden (SBAS), and Expressed Emotion (CFI) were gathered from 41 schizophrenia outpatients and their mothers. Approximately one quarter of the variance in Critical Comments (CCs) and Emotional Overinvolvement (EOI) was explained using path analysis. Mothers' CCs were associated with more severe excitement in the patient, with lower Neuroticism, and greater burden in the mother. Higher EOI was explained by greater Conscientiousness and burden in the mother; patient depression had a weak indirect effect on maternal EOI. These results characterize the high EE mother as low in neuroticism and high in conscientiousness with a particular sensitivity to excitement and depression in the patient.     

Familial expressed emotion: outcome and course of Israeli patients with schizophrenia

We investigated the validity of expressed emotion (EE) in Israel. The study sample consisted of 108 patients with schizophrenia and 15 with schizoaffective disorder, and their key relatives. EE was rated with the Five Minute Speech Sample (FMSS). Patient households were categorized by EE and its two components: criticism and emotional overinvolvement. Patients were rated with the Brief Psychiatric Rating Scale (BPRS) at admission, at discharge, and 6 months after discharge. Readmissions were determined over a 9-month period. High EE and particularly high criticism were significantly associated with poorer outcome (higher rate of and earlier readmissions, and higher BPRS score at followup) and worse illness course (higher annual number of prior psychiatric hospital admissions). Odds ratios between high EE and high criticism and readmission were 2.6 and 3.5, respectively. The strongest predictor of earlier readmission was the interaction of high criticism x poor compliance with medication. The results converge to further confirm the notion that familial EE is a valid crosscultural predictor of the clinical course of schizophrenia. Moreover, EE has predictive power in very chronic samples. Criticism appears to be the crucial EE component linked with short-term outcome. Treatment aimed at reducing high criticism is warranted. The FMSS appears to have predictive validity.     

Perceived criticism in schizophrenia: a comparison of instruments for the assessment of the patient's perspective and its relation to relatives' expressed emotion

Administrative datasets can provide information about mental health treatment in real world settings; however, an important limitation in using these datasets is the uncertainty regarding psychiatric diagnosis. To better understand the psychiatric diagnoses, we investigated the diagnostic variability of schizophrenia and major depression in a large public mental health system. Using schizophrenia and major depression as the two comparison diagnoses, we compared the variability of diagnoses assigned to patients with one recorded diagnosis of schizophrenia or major depression. In addition, for both of these diagnoses, the diagnostic variability was compared across seven types of treatment settings. Statistical analyses were conducted using t tests for continuous data and chi-square tests for categorical data. We found that schizophrenia had greater diagnostic variability than major depression (31% vs. 43%). For both schizophrenia and major depression, variability was significantly higher in jail and the emergency psychiatric unit than in inpatient or outpatient settings. These findings demonstrate that the variability of psychiatric diagnoses recorded in the administrative dataset of a large public mental health system varies by diagnosis and by treatment setting. Further research is needed to clarify the relationship between psychiatric diagnosis, diagnostic variability and treatment setting.     

Family expressed emotion and relapse in schizophrenia in 24 urban American patients

The authors examined the correlation between family expressed emotion and relapse in 24 schizophrenic patients in a predominantly inner-city American setting. They found a significant correlation between relapse and high expressed emotion in family members; the level of family expressed emotion was somewhat higher than that reported in previous studies. The findings suggest that the impact of expressed emotion may vary in different sociocultural populations.     

A functional magnetic resonance imaging paradigm of expressed emotion in schizophrenia

Chronic exposure to adverse interpersonal environment in schizophrenia is associated with vulnerability to relapse. The construct of expressed emotion (EE) measures the quality of interpersonal environment, of which criticism is a main component. To use functional magnetic resonance imaging and to investigate the neural basis of vulnerability of schizophrenic patients to EE, the effects of critical comments on brain mechanisms in 11 patients with schizophrenia were examined, comparing evoked responses to familiar (key relative) and unfamiliar (matched stranger) critical and neutral commentary. High EE stimuli evoked enhanced activation of brain regions concerned with the processing of aversive social information. Activations in the right BA44, rostral anterior cingulate, middle superior frontal gyrus, bilateral middle frontal gyrus, left temporal pole, left inferior frontal gyrus, and left insula were significantly modulated to familiar criticism. Such a pattern of neural response may represent a putative neural network responsible for mediating High EE in schizophrenia.     

Interpersonal control and expressed emotion in families of persons with schizophrenia: change over time

This study examined communication patterns in 62 families of persons with schizophrenia, comparing families with relatives who were low expressed emotion (EE) at the beginning and end of a 2-year study, those who were high EE at the beginning and end, and those whose EE status changed. Interaction was coded with the Relational Control Coding System and analyzed as a Markov process. Dialogues in the stable low-EE and stable high-EE families were rather similar initially, and both groups showed increasing flexibility at year 1. However, at year 2, low-EE dyads showed increasingly complex structure and flexibility in control, but high-EE dyads showed simpler structure and rigidly controlling patterns. When EE status changed, so did the structure of the dialogues and the patterning of control. Although earlier research found more "tightly joined" systems in families of high-EE relatives, it may be that over time, these family members distance from each other and so are less connected. It is also possible that relatives who remain high EE despite intervention are a subset of high-EE relatives who need more support or different therapeutic approaches to maintain change.     

The impact of education about schizophrenia on relatives varying in expressed emotion

The demand for information by relatives and the success of family intervention programs with an initial didactic component has resulted in a proliferation of educational interventions in schizophrenia. The present study assesses the impact of a single educational session on relatives of recent-onset schizophrenic patients. Results suggest that relatives who participated in family education experience an increased sense of support from the treatment team and a nearly significant tendency toward a decrease in self-blame regarding the schizophrenic illness. Despite findings in previous studies suggesting information acquisition immediately after education and retention after 6 months, the present study found no information retention after a 2-month period. After family education, relatives rated as high in expressed emotion (EE) reported a significantly increased sense of understanding of the illness and expressed increased feelings of support from the treatment team, whereas low EE relatives did not change significantly in these attitudes as a function of the educational session. Low EE relatives demonstrated more actual information about the illness and were less likely to perceive the symptoms as being done intentionally to bother them.     

Impaired emotion perception in schizophrenia: a differential deficit

We investigated previously reported contradictory findings regarding the nature of deficits in emotion perception among patients with schizophrenia. Some studies have concluded that such deficits are due to a generalized impairment in visual processing of faces, while others have found it to be restricted to facial emotional expressions. We examined 37 patients and 32 healthy controls, matched on age and education, using three computerized tests: matching facial identity, matching facial emotional expressions, and discrimination of subtle differences in the valence of facial emotional expressions. Our results showed impaired matching of emotions in patients with schizophrenia. This impairment did not manifest on tasks that depended on perceiving the identity of faces or cues of the relative valence of facial emotional expressions. Our findings support the differential deficit hypothesis of emotion perception in schizophrenia.     

The relationships between expressed emotion,affective style and communication deviance in recent-onset schizophrenia

The relationships between expressed emotion (EE), affective style (AS) and communication deviance (CD) were studied during hospitalization and after discharge. EE was measured with both the Camberwell Family Interview (CFI) and the Five-Minutes Speech Sample (FMSS). The study subjects were patients with recent-onset schizophrenia and related disorders, who were consecutively admitted to an in-patient unit for adolescents, and their parents. The results revealed that CFI/EE was significantly correlated with AS criticism scores during hospitalization, but did not predict AS scores after discharge. FMSS/EE correlated significantly with AS criticism when both measures were administered after discharge. During hospitalization, FMSS/EE was not significantly correlated with AS. No consistent relationship was found between CD and both affective factors (EE and AS). It is concluded that EE and AS overlap with regard to level of criticism when both measures are administered over a short period of time and independent of the time of assessment. In addition, the results indicate that affective and communication factors identify independent family attributes.     

A cross-cultural study on expressed emotion in carers of people with dementia and schizophrenia: Japan and England

Expressed emotion (EE) research has been productive in investigating the influence of the interpersonal environment on a range of disorders. The majority of EE research on the influence of carers has been carried out in the west. This is the first EE study of the carers of people with dementia in Japan. The aim of this study was to investigate the relationships between EE status and aspect of burden through cross-cultural comparison of the two countries, Japan and England, with large cultural and linguistic differences. Comparisons were made between samples of EE of carers of dementia and schizophrenic patients. In total, data on 80 carer/relative-patient dyads were collected and examined: (1) 20 Japanese carers of people with dementia (JD), (2) 20 English carers of patients with Alzheimer's disease (ED), (3) 20 Japanese relatives of patients with schizophrenia (JS), and (4) 20 English relatives of patients with schizophrenia (ES). The Camberwell Family Interview was administered in each country to ascertain levels of EE. Large differences between Japan and England were found in the frequency of critical comments, in which ES>ED>JS>JD. EE correlated significantly with burden in the JD sample alone. With an operational cut-off of 2CC (CC, critical comments), EE correlated significantly with cognitive impairment as well as with clinical severity in the JD sample. There was a tendency for lower expression of both positive and negative emotional reactions towards family members in the Japanese sample. The results of this study indicate that EE is an appropriate measure for use with carers of sufferers of dementia and can be utilized across different cultures. However, flexibility with the cut-offs may be required in Eastern cultures. This needs to be tested on larger samples with sensitivity to illness and cross-cultural differences.     

Predictors of components of expressed emotion in major caregivers of Turkish patients with schizophrenia

Background Expressed emotion (EE) is a concept reflecting the emotional atmosphere of the home environment. Specific components of EE, namely criticism, hostility and emotional over-involvement, have been found to be important predictors of relapse for schizophrenic patients. The main aim of this study was to examine the predictive power of patient and caregiver characteristics and caregivers' perceptions of frequency, coping, distress/discomfort, control of symptom behaviours by the patient, and attributions on locus of causality for the development of the illness on two components of EE (criticism/hostility and emotional over-involvement) in a sample of major caregivers of Turkish schizophrenic patients. Methods Seventy-two caregivers of schizophrenic patients were administered a set of questionnaires tapping socio-demographic and illness-related variables, the family questionnaire tapping perceived frequency, distress/discomfort, coping and control of symptom behaviours, causal attributions for illness and, finally, the Expressed Emotion Scale in the hospital setting. Results The results showed that caregivers' perceptions of coping with specific symptom behaviours decreased criticism/hostility (C/H), whereas perceptions of higher frequency of symptom behaviours increased C/H. For emotional over-involvement (EOI), the number of individuals living in the household, being the mother, father or the spouse, perceptions of coping with symptom behaviours and reported distress/discomfort about symptom behaviours were significant predictors. Conclusions Caregivers' perceptions of their ability to cope with symptom behaviours and their reported distress due to these behaviours are important variables related to components of EE and need to be targets in intervention studies. The cultural and clinical implications of the results for the management of schizophrenia and for support for the caregivers are discussed. Accepted: 26 September 2001     

Ethnicity, expressed emotion, and communication deviance in family members of patients with schizophrenia

This study examined the relationships among expressed emotion (EE), communication deviance (CD), and ethnicity in a sample of 57 white, Latino, and black relatives of patients with schizophrenia. A new method of assessing CD from the Five Minute Speech Sample was also developed and evaluated against an existing method (the Camberwell Family Interview; CFI). As hypothesized, high expressed emotion rated (from the CFI) was associated with higher levels of CD, and the Five Minute Speech Sample and CFI methods of assessing CD were concordant. CD statements made by white family members focused most on patient behaviors/symptoms that reflected a lack of independent functioning. CD statements of Latino and black relatives, however, focused most on patient behaviors that interfered with the family's interdependent functioning. Family members may have particular difficulty communicating coherently when discussing patients' inability to uphold important values and behaviors that are sanctioned by their ethnic background.     

Age, expressed emotion, and interpersonal control patterning in families of persons with schizophrenia

Expressed emotion (EE) is a measure of a relative's attitude toward a person with a mental disorder as reflected by comments made to an interviewer. Over the years, an impressive body of research has been generated in attempts to explain the relationship of EE and course of illness, particularly in regard to schizophrenia. Past analyses have demonstrated two common patterns of interpersonal control in families with high-EE relatives. The first was that the relative and patient competed for 'who's in charge', with both rigidly asserting control. The other was that the relatives responded rigidly in one control mode no matter what the offspring was saying. In this study, we tested whether the difference in patterning was due to the patients being older. Study participants were 71 relative-patient dyads. EE was measured with the Five-Minute Speech Sample, the Family Problem-Solving Task was used to generate interaction, and interaction data were coded with the Relational Control Coding System. Multilevel modeling was used to estimate a model with verbal exchanges as Level 1, relatives' EE as Level 2, and age of the patient as Level 3. Results showed that age attenuated the relationship between the patient's message and the parent's response, and this effect was stronger in families with high-EE relatives. This effect may reflect disengagement on the part of the relative, the patient, or both. The over-responsive families may need advice on how to create more distance, or how to be more objective, but the distant families may need more support and encouragement to communicate and problem-solve.     

The measurement of expressed emotion: a review.

Expressed emotion refers to the affective attitudes and behaviours (i.e., criticism, hostility and emotional overinvolvement) of relatives toward a family member with a psychiatric illness. In this article, the Camberwell Family Interview, the standard method used to assess expressed emotion, and alternative approaches to the measurement of expressed emotion are reviewed. While there is a reasonable correspondence between ratings derived from the Camberwell interview and the less arduous alternative methods, the association is not perfect. In addition, the conceptual similarities and prognostic utility of these measures require replication and further exploration. Of the alternative assessment methods available, the use of the Five Minute Speech Sample or the Level of Expressed Emotion Scale as screening devices is recommended.     

Ethnicity, expressed emotion, and schizophrenia patients' perceptions of their family members' criticism

Expressed emotion is a widely researched construct. However, less is known about patients' own perceptions of their relatives' expressed emotion. Using a sample of 42 patient/family member dyads with schizophrenia, we examined the concordance between the number of criticisms expressed by relatives during the Camberwell Family Interview and patients' perceptions of how critical they perceived their relative to be. As predicted, white and Latino family members who expressed more criticism during the Camberwell Family Interview were indeed perceived as more critical by patients. Among blacks, however, no significant association was found between relatives' expressed criticism and patients' perceptions of their relatives' criticism. Findings from this study suggest that cultural/ethnic values may influence how criticism from relatives is perceived and experienced by patients.     

Interpersonal control,expressed emotion,and change in symptoms in families of persons with schizophrenia

This study examined the relationships of expressed emotion (EE), change in symptoms in schizophrenia, and interpersonal control patterns in relatives over a 2-year period. Subjects were 56 persons with schizophrenia and their relatives who participated in the NIMH Treatment Strategies in Schizophrenia (TSS) longitudinal study. The relationships among EE, interpersonal control as measured by the Relational Control Coding System (RCCS), and levels of symptoms at each assessment point were analyzed longitudinally with hierarchical linear modeling (HLM).No relationship was found between EE and symptoms, nor did control appear to contribute to symptoms. High-EE relatives reacted more strongly to symptom change than low-EE relatives and in opposite directions. EE may be an indicator of responsiveness rather than either a cause or result of symptoms. Understanding how EE attitudes impact the struggles patients and relatives have in coping with schizophrenia is crucial to knowing how clinicians can support these families most effectively.     

Acculturation and expressed emotion in Caucasian, Latino, and black relatives of patients with schizophrenia

High expressed emotion (high EE) in family members (high levels of criticism, emotional overinvolvement, and/or hostility) has been found to be predictive of a poorer course of illness for patients with schizophrenia in many different cultures. Acculturation has also been found to relate to symptom severity and clinical course in a number of disorders (e.g., substance abuse, schizophrenia). There is reason to believe that acculturation may interact with EE, however, this relationship has yet to be examined systematically. The present study evaluated the relationship between acculturation and EE in a sample of 57 Caucasian, Latino, and black caregivers of patients with schizophrenia. Drawing from earlier research, it was hypothesized that more acculturated Caucasian and Latino relatives and less acculturated black relatives would be designated as high EE. Hypotheses were partially supported as results demonstrated that greater acculturation was associated with high EE for Latinos and low EE for blacks.