Family interactions and the course of schizophrenia in African American and White patients

Relatives' critical and intrusive behavior with patients, patients' odd or unusual thinking with relatives, and the course of schizophrenia were examined. Seventy-one African American and White patients (each with 1 relative) completed 2 problem-solving discussions. Relatives' critical and intrusive behavior with patients and patients' odd or unusual thinking with relatives were assessed, and patients were followed for 2 years. For African American patients, high levels of relatives' critical and intrusive behavior were associated with better outcome. For White patients, low levels of both relatives' critical and intrusive behavior and patients' odd or unusual thinking with relatives were associated with better outcome. The results suggest that during family interactions, seemingly negative behaviors may be perceived as a sign of caring and concern by African Americans. For Whites, the combination of patients' odd or unusual thinking with relatives and relatives' critical and intrusive behavior toward patients may be especially predictive of an adverse course.     

A sociocultural stress, appraisal, and coping model of subjective burden and family attitudes toward patients with schizophrenia

A sociocultural stress, appraisal, and coping model was developed to understand relatives' burden of care and negative affective attitudes toward patients with schizophrenia. Ninety-two African American and 79 White patients and a significant other (80% mothers) completed 2 10-min family problem-solving discussions. In addition, the Kreisman Rejection Scale and a global self-report rating of family burden were administered to relatives, and a self-report rating of substance use was administered to patients. Results indicated that subjective burden of care and patients' odd and unusual thinking during the family discussion each independently predicted relatives' attitudes toward patients, suggesting that negative attitudes are based in part on both patients' symptoms and perceived burden of care. African American relatives' perceived burden was also predicted by patients' substance abuse. Finally, White family members were significantly more likely than African Americans to feel burdened by and have rejecting attitudes toward their schizophrenic relative suggesting that cultural factors play an important role in determining both perceived burden and relatives' attitudes toward patients.     

Difficulty in implementing a family intervention for bipolar disorder: the predictive role of patient and family attributes

Family affect was examined as a predictor of difficulty implementing a 9-month, manual-based, psychoeducational family therapy for recently manic bipolar patients. Prior to therapy, family members were administered measures to assess both their expressed emotion and affective behavior during a family interaction task. Following family treatment, both therapists and independent observers rated the overall difficulty of treating the family, and therapists also rated each participant's problem behaviors during treatment, in the areas of affect, communication, and resistance. Therapists regarded affective problems among relatives and resistance among patients as central in determining the overall difficulty of treating the family. Relatives' critical behavior toward patients during the pretreatment interaction task predicted both independent observers' ratings of overall treatment difficulty and therapists' perceptions of relatives' affective problems during treatment. Moreover, patients' residual symptoms predicted independent observers' ratings of overall difficulty and therapists' perceptions of patients' resistance to the family intervention. Results suggest that difficulties in conducting a manual-based family intervention can be predicted from systematic, pretreatment family and clinical assessment.     

Expressed emotion and attributions in the relatives of bipolar patients: an analysis of problem-solving interactions

Among the relatives of schizophrenic and depressed patients, high expressed emotion (EE) attitudes are associated with "controllability attributions" about the causes of patients' symptoms and problem behaviors. However, previous studies have judged EE attitudes and causal attributions from the same assessment measure, the Camberwell Family Interview (CFI; C. E. Vaughn & J. P. Leff, 1976). The authors examined causal attributions among relatives of 47 bipolar patients, as spontaneously expressed to patients in family problem-solving interactions during a postillness period. Relatives rated high EE during the patients' acute episode (based on the CFI) were more likely than relatives rated low EE to spontaneously attribute patients' symptoms and negative behaviors to personal and controllable factors during the postillness interactional assessment. Thus, the EE-attribution linkage extends to the relatives of bipolar patients evaluated during a family interaction task.     

Is Expressed Emotion an Index of a Transactional Process? II. Patient's Coping Style

This article examines the extent to which expressed emotion (EE) indexes not only relatives' behavior toward schizophrenic patients but also patients' behavior toward their relatives. The coping styles (CS) of schizophrenic patients were assessed during interactions with their parents and were compared with parental EE attitudes assessed during an acute hospitalization and during the aftercare period. It was found that parental EE attitudes measured during the inpatient period strongly predicted patients' outpatient transactional behavior: patients interacting with low-EE relatives showed significantly fewer critical and more autonomous statements than patients interacting with high-EE relatives. Further, the dominant patient coping style (autonomous, neutral, externalizing, or internalizing) was strongly related to the relatives' interactional affective style (AS) and to their pattern of EE attitudes. Patient coping style was not related to clinical attributes of these patients themselves. This article and its preceding companion (17) together suggest that EE indexes a transactional process so that the quality of both parents' and patients' transactional behaviors may predict subsequent patient functioning.     

Clinicians' fidelity to a manual-based family treatment as a predictor of the one-year course of bipolar disorder

This study assessed whether therapist adherence to the family focused treatment model for patients with bipolar disorder and their relatives was associated with patient outcomes at one year after treatment entry. A total of 78 videotaped sessions of FFT consisting of 26 families with a member with bipolar disorder (3 sessions/family) were rated on fidelity using the Therapist Competence/Adherence Scale (TCAS; see Endnote 1, p. 130). Patients' outcomes (relapse status) were assessed using the Brief Psychiatric Rating Scale (BPRS) and selected items from the Schedule of Affective Disorders and the Schizophrenia-Change (SADS-C) scale (measured at 3-month intervals for 12 months). Contrary to expectations, therapist fidelity was not related to overall outcome as assessed by the BPRS and the SADS-C. Among patients who did relapse, higher levels of cooperation among therapists predicted a later date for relapse than did lower levels of cooperation. Surprisingly, and in opposition to the study's hypotheses, patients who were hospitalized because of relapses had therapists who were rated as more competent in their ability to conduct the problem-solving module of FFT. Study implications are discussed.     

Attributions and affective reactions of family members and course of schizophrenia.

The authors tested an attribution-affect model of schizophrenic relapse attending to the role of families' positive affect (warmth) and negative affect (criticism). Coders listened to interviews of 40 family members taken from C. E. Vaughn, K. S. Synder, S. Jones, W. B. Freeman, and I. R. Falloon (1984) and rated their attributions of controllability for the symptoms and behaviors of their relatives with schizophrenia. For family members not designated as emotionally overinvolved, perceptions that their ill relatives' symptoms and behaviors were under the patients' control were related to family members' warmth and criticism and to patients' clinical outcomes. Of the affective reactions, only criticism predicted outcome. In addition, patients' use of street drugs was related to attributions, criticism, and outcome. Together these findings suggest that families' attributions and criticism are important in understanding the relationship between family factors and course of illness.     

Expressed emotion attitudes and individual psychopathology among the relatives of bipolar patients

This study investigated the relationships between expressed emotion (EE) and individual psychopathology among 82 biological and non-biological relatives of 66 patients with bipolar I disorder. Relatives' psychopathology was assessed via the Structured Clinical Interview for DSM-III-R, Patient Version (SCID-P) and the General Behavior Inventory (GBI), a self-report measure of lifetime subsyndromal mood disturbances. We hypothesized that relatives who held high-EE critical, hostile, and/or overinvolved attitudes toward their bipolar family member, as measured via the Camberwell Family Interview, would be more likely to have DSM-III-R Axis I diagnoses on the SCID, as well as more mood and temperamental disturbances on the GBI, than those who held low-EE attitudes. The findings did not support a significant relationship between overall EE status and psychopathology in family members. However, relatives without significant Axis I pathology scored significantly higher than those with Axis I pathology on one measure of EE, emotional overinvolvement. The findings are discussed with reference to explanations for the genesis of high-EE attitudes.     

A comparison of depressed patients with and without borderline personality disorder: implications for interpreting studies of the validity of the bipolar spectrum

The nosological status of borderline personality disorder as it relates to the bipolar disorder spectrum has been controversial. Studies have supported, in part, the validity of the bipolar spectrum by demonstrating that these patients, compared to patients with nonbipolar depression, are characterized by earlier age of onset of depression, recurrent depressive episodes, comorbid anxiety and substance use disorders and increased suicidality. However, all of these factors have likewise been found to distinguish depressed patients with and without borderline personality disorder. A family history of bipolar disorder is one of the few disorder specific validators. In the present study from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we compared the demographic and clinical characteristics of depressed patients with and without borderline personality disorder. We hypothesized that many of the factors used to validate the bipolar spectrum will also distinguish depressed patients with and without borderline personality disorder except, however, a family history of bipolar disorder. Two thousand nine hundred psychiatric outpatients at Rhode Island Hospital were evaluated with the Structured Clinical Interview for DSM-IV (SCID) and Structured Interview for DSM-IV Personality Disorders (SIDP-IV). Family history information regarding first-degree relatives was obtained from the patient using the Family History Research Diagnostic Criteria. One hundred and one patients with borderline personality disorder plus major depressive disorder were compared to 947 patients with major depressive disorder alone on the prevalence of bipolar disorder validators. Compared to depressed patients without borderline personality disorder, depressed patients with borderline personality disorder had a younger age of onset, more depressive episodes, a greater likelihood of experiencing atypical symptoms and had a higher prevalence of comorbid anxiety disorders, substance use disorders, and number of previous suicide attempts. The depressed patients with borderline personality disorder did not significantly differ from the patients without borderline personality disorder on morbid risk for bipolar disorder in first degree relatives. In addition, patients with a diagnosis of bipolar disorder had a significantly higher morbid risk of bipolar disorder in first degree relatives than the borderline personality disorder group. The findings indicate that many factors used to validate the bipolar spectrum are not disorder specific. These results raise questions about studies of the validity of the broad bipolar spectrum that do not assess borderline personality disorder. Our results do not support inclusion of borderline personality disorder as part of the bipolar spectrum.     

The relationship of relatives' attributions to their expressed emotion and to patients' improvement in treatment for anxiety disorders

In a test of Hooley's (1987) attributional model of expressed emotion (EE), attributions for negative behaviors and events in patients' lives were examined in relatives of 74 outpatients with panic disorder with agoraphobia or obsessive-compulsive disorder. Attributions were extracted from 10-minute problem-solving interactions between relatives and patients, whereas EE was assessed during a separate interview with the relative. Consistent with prior findings in relatives of individuals with other disorders, relatives who made greater proportions of attributions of patient responsibility demonstrated significantly higher levels of EE-hostility. In addition, nonspousal relatives (mostly parents) who attributed any negative behaviors or events to a patient's disorder were significantly higher in emotional overinvolvement (EOI); no such relationship was found for spouses. Finally, patients with relatives who made attributions to the patient's disorder received less benefit from behavior therapy than did those whose relatives made no such attributions, even when EE variables were controlled.     

Family Functioning and the Course of Adolescent Bipolar Disorder

The symptoms of bipolar disorder affect and are affected by the functioning of family environments. Little is known, however, about the stability of family functioning among youth with bipolar disorder as they cycle in and out of mood episodes. This study examined family functioning and its relationship to symptoms of adolescent bipolar disorder, using longitudinal measures of family cohesion, adaptability, and conflict. Parent- and adolescent-reported symptom and family functioning data were collected from 58 families of adolescents with bipolar disorder (mean age = 14.48 ± 1.60; 33 female, 25 male) who participated in a 2-year randomized trial of family-focused treatment for adolescents (FFT-A). Cohesion and adaptability scores did not significantly change over the course of the study. Parent-reported conflict prior to psychosocial treatment moderated the treatment responses of families, such that high-conflict families participating in FFT-A demonstrated greater reductions in conflict over time than low-conflict families. Moreover, adolescent mania symptoms improved more rapidly in low-conflict than in high-conflict families. For all respondents, cohesion, adaptability, and conflict were longitudinally correlated with adolescents’ depression scores. Finally, decreases in parent-reported conflict also predicted decreases in adolescents’ manic symptoms over the 2-year study. Findings suggest that family cohesion, adaptability, and conflict may be useful predictors of the course of adolescent mood symptoms. Family conflict may be an important target for family intervention in early onset bipolar disorder.     

How do Hostile and Emotionally Overinvolved Relatives View Relationships?: What Relatives' Pronoun Use Tells Us

Expressed emotion (EE) has been linked to negative outcomes for a variety of psychiatric illnesses. Despite development of effective interventions to reduce EE, relatively little is known about EE's antecedents or maintaining factors. The present study uses a novel methodology (measurement of pronouns used by relatives during the Camberwell Family Interview [CFI] or a problem-solving interaction with the patient) to explore possible cognitive correlates of EE. Participants were 98 outpatients with obsessive-compulsive disorder or panic disorder with agoraphobia and their primary relative. Results showed that relatives' pronoun use was stable across situations. Relatives' hostility and criticism, as measured by objective coding of relatives' behavior during the CFI and interactions, respectively, were related to relatives' decreased we-focus and increased me-focus in the 2 situations. In contrast to expectations, relatives' emotional overinvolvement was related to their decreased we-focus during CFIs and interactions. Results support the value of using pronouns as a means to explore important aspects of relationship functioning.     

Communication deviance in families of schizophrenic and manic patients

Levels of communication deviance (CD) distinguish parents of schizophrenic patients from parents of nonpsychotic patients, but the prevalence of intrafamilial CD in other psychotic disorders has not been examined. Levels of CD were compared across biological parents of schizophrenic (n = 39) and bipolar manic (n = 16) patients and across patients themselves. CD ratings were based on Thematic Apperception Test protocols (parents only) and family interactions (parents and patients). Total levels of CD did not distinguish between groups of parents or patients. However, instances of odd word usage were more frequent among parents of manic patients than among parents of schizophrenic patients on both CD measures. Also, during the interaction task, odd word usage was more frequent among manic patients, whereas schizophrenic patients made more ambiguous references. Results suggest that high levels of intrafamilial CD are not unique to schizophrenia.     

Somatosensory processing and schizophrenia liability: proprioception, exteroceptive sensitivity, and graphesthesia performance in the biological relatives of schizophrenia patients

In the present study, the authors examined somatosensory processing in 30 biological relatives of persons with schizophrenia (hereafter called "schizophrenia relatives"), 30 biological relatives of persons with bipolar affective disorder (psychiatric family control subjects), and 30 healthy control subjects with no family history of psychopathology. All 3 groups completed a weight discrimination task, a 2-point discrimination task, and a complex cognitive somatosensory task (i.e., graphesthesia). The schizophrenia relatives performed significantly worse on all 3 somatosensory tasks compared with both the healthy control subjects and the bipolar relatives. The healthy control subjects and psychiatric family control subjects showed no significant differences on any of the somatosensory tasks. Within the weight discrimination and 2-point discrimination tasks, schizophrenia relatives showed group differences on the d' index, the measure of sensitivity, whereas all 3 groups did not differ on lnbeta, the measure of response bias, suggesting a genuine difference in weight and touch sensitivity. The d' value of the weight discrimination task was significantly associated with both the cognitive-perceptual factor and negative symptom factor of the clinical questionnaire (e.g., Schizotypal Personality Questionnaire; SPQ), whereas the 2-point discrimination d' value and graphesthesia scores were significantly associated only with the cognitive-perceptual factor of the SPQ. Implications for the possible relation between somatosensory task performance and schizophrenia liability are discussed.     

Relatives' affective style and the expression of subclinical psychopathology in patients with schizophrenia

High expressed emotion (EE) is a measure of hostile, critical, and emotionally overinvolved attitudes expressed by a family member about a psychiatrically ill relative during an interview conducted in the patient's absence. EE is a robust predictor of relapse in schizophrenia, yet attempts to identify clinical characteristics that differentiate patients from high versus low EE families have mostly yielded negative findings. However, in a previous study, we found that patients with schizophrenia from high EE families exhibited greater levels of subclinical psychopathology when interacting with family members than did patients from low EE families. Patients from high EE families (N=32) also demonstrated considerable heterogeneity in their expression of subclinical psychopathology. The present study extends our previous work by demonstrating that this heterogeneity in patient subclinical psychopathology was associated with the extent to which family members expressed high EE congruent behaviors--as measured by the affective style (AS) coding system--when directly interacting with their patient-relative. Elevations in anxious/agitated behaviors and hostile/unusual behaviors were observed among patients whose high EE relatives behaved in a manner consistent with their EE status. These findings support a complex, bidirectional model of the role of high EE attitudes in influencing the course of schizophrenia.     

A preliminary study of autobiographical memory in remitted bipolar and unipolar depression and the role of imagery in the specificity of memory

Autobiographical memory was investigated in a sample of 19 individuals with remitted bipolar affective disorder and a community sample of 16 individuals with remitted unipolar depression who had similar low levels of current symptoms. Each participant was prompted to recall one positive memory and one negative memory, to rate it on several scales, and to describe it in detail. Relative to the remitted unipolar group, the remitted bipolar group reported more general than specific negative memories and more frequent recollections of the negative memory during their everyday life. Across the sample, 95% of all specific memories involved a mental image, whereas only 56% of all general memories involved a mental image, suggesting a role of imagery in the retrieval of a specific memory. Characteristic examples of memories are provided. These results are preliminary yet they suggest that patients with bipolar disorder in remission may show memory characteristics that are often associated with symptomatic unipolar depression.     

A preliminary study of autobiographical memory in remitted bipolar and unipolar depression and the role of imagery in the specificity of memory

Autobiographical memory was investigated in a sample of 19 individuals with remitted bipolar affective disorder and a community sample of 16 individuals with remitted unipolar depression who had similar low levels of current symptoms. Each participant was prompted to recall one positive memory and one negative memory, to rate it on several scales, and to describe it in detail. Relative to the remitted unipolar group, the remitted bipolar group reported more general than specific negative memories and more frequent recollections of the negative memory during their everyday life. Across the sample, 95% of all specific memories involved a mental image, whereas only 56% of all general memories involved a mental image, suggesting a role of imagery in the retrieval of a specific memory. Characteristic examples of memories are provided. These results are preliminary yet they suggest that patients with bipolar disorder in remission may show memory characteristics that are often associated with symptomatic unipolar depression.     

The Role of the Family in the Course and Treatment of Bipolar Disorder

ABSTRACT— Bipolar disorder is a highly recurrent and debilitating illness. Research has implicated the role of psychosocial stressors, including high expressed-emotion (EE) attitudes among family members, in the relapse–remission course of the disorder. This article explores the developmental pathways by which EE attitudes originate and predict relapses of bipolar disorder. Levels of EE are correlated with the illness attributions of caregivers and bidirectional patterns of interaction between caregivers and patients during the postepisode period. Although the primary treatments for bipolar disorder are pharmacological, adjunctive psychosocial interventions have additive effects in relapse prevention. Randomized controlled trials demonstrate that the combination of family-focused therapy (FFT) and pharmacotherapy delays relapses and reduces symptom severity among patients followed over the course of 1 to 2 years. The effectiveness of FFT in delaying recurrences among adolescents with bipolar disorder and in delaying the initial onset of the illness among at-risk children is currently being investigated.     

Causal attributions about schizophrenia in families in China: expressed emotion and patient relapse

Previous studies have indicated a robust link between relatives' causal attributions and levels of expressed emotion (EE). However, these studies have primarily been conducted in Western cultures. The current study, conducted in China, examined the spontaneous causal attributions made by 54 relatives of schizophrenia patients during the Camberwell Family Interview. Chinese relatives made few controllable and personal attributions overall. Yet as predicted, highly critical and/or hostile EE relatives attributed patients' negative behaviors to more controllable and personal factors. High EE and controllable attributions positively predicted relapse, whereas personal attributions unexpectedly protected against relapse. EE mediated the effect of controllable, but not personal, attributions on relapse. Relatives' use of a particular Chinese characteristic (narrow-mindedness) was integral to the personal dimension's protective effect.     

Mood induced cognitive and emotional reactivity, life stress, and the prediction of depressive relapse

This study examined a group of participants who were fully remitted from a previous episode of major depressive disorder, and evaluated the role of cognitive and emotional reactivity to a mood challenge, and life stress in the prediction of relapse. Fifty-two participants were evaluated during remission, and their reactivity (i.e., change in dysfunctional attitudes and emotional state) to a depressed mood induction was evaluated. The cohort was followed up 12 months after the initial assessment. Thirty-five percent of the sample experienced a relapse during the follow-up period. Relapse was predicted by higher rates of life stress, and lower levels of emotional reactivity (specifically less reduction in happiness) to the mood induction during the initial assessment. Cognitive reactivity to the mood induction did not predict relapse, nor did the interaction between cognitive reactivity and life stress. These findings are discussed in terms of recent literature suggesting that depression is associated with insensitivity to emotion context, such that depressed individuals display blunted emotional responses to affective stimuli, including sadness-inducing stimuli. These findings suggest that insensitivity to emotional context may also be a characteristic of euthymic individuals at risk of relapse.