Attribution and expressed emotion in the relatives of patients with schizophrenia.

Indexes of expressed emotion (EE) in 58 relatives of patients with schizophrenia were related to those relatives' spontaneously expressed causal beliefs about the illness and about related symptoms and behaviors. Relatives made attributions predominantly to factors external, universal, and uncontrollable from their own perspective, and to factors internal, universal, and uncontrollable from the patient's perspective. Low-EE relatives were similar in their attributions to emotionally overinvolved relatives. Compared with these two groups, critical and/or hostile relatives made more attributions to factors personal to and controllable by the patient. Subsequent analyses suggested that hostile relatives were further characterized by making more attributions to factors internal to the patient and by making attributions with fewer causal elements.     

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.     

Controllability perceptions and reactions to symptoms of schizophrenia: a within-family comparison of relatives with high and low expressed emotion

In a sample of 35 family members of patients with recent-onset schizophrenia, attributions of control and the content of critical comments were compared for 2 relatives of the same household who held discrepant expressed emotion (EE) attitudes (1 high and 1 low) toward their mentally ill family member. Attributions and the content of critical comments were also compared for low-EE relatives from low-EE homes versus low-EE relatives from high-EE homes. Our results indicate that high-EE relatives tend to attribute more control over behavior to patients than do low-EE relatives of the same patient. In addition, low-EE relatives from high-EE homes attribute more behavioral control to patients than do low-EE relatives from low-EE homes. These findings suggest that EE status is linked to attributions of control over behaviors, but additional patient factors or influences among family members may also affect EE attitudes.     

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.     

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 causal attributions in relatives of post-traumatic stress disorder patients

This study investigates the relationship between expressed emotion (EE) and causal attributions in relatives of post-traumatic stress disorder (PTSD) patients, and examines the contributions of EE and attributions to patient outcomes. Thirty-eight relatives of patients with PTSD participating in a treatment trial were assessed on EE, causal attributions for patient problems and nature of attributions. Patients' PTSD symptoms at 6 and 12 months were assessed. Criticism and hostility in relatives were associated with attributing problems to factors controllable by patients. Relatives with marked emotional over-involvement (EOI) had an attributional profile similar to low EE relatives. Deficits in normal behaviour ("negative symptoms") were perceived as more controllable, internal and stable than were more obvious signs of an illness or mental health problem such as hypervigilance and intrusive thoughts and nightmares ("positive symptoms"). Irritability or anger was perceived as more controllable and personal than any other problem. Hostility was associated with less psychological understanding. EE (hostility) but not attributions was found to predict clinical outcome. The results are consistent with previous studies of relatives of schizophrenia patients. The study suggests a need for interventions, which focus on helping relatives to reappraise the impact of PTSD.     

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.     

Family transactions and relapse in bipolar disorder

This study examined whether patient symptoms and relatives' affective behavior, when expressed during directly observed family interactions, are associated with the short-term course of bipolar disorder. Twenty-seven bipolar patients and their relatives participated in two 10-minute family interactions when patients were discharged after a manic episode. Results indicated that patients who showed high levels of odd and grandiose thinking during the interactions were more likely to relapse during a 9-month followup period than patients who did not show these symptoms during the family discussions. Relapse was also associated with high rates of harshly critical and directly supportive statements by relatives. Patients' odd thinking and relatives' harsh criticism were significantly more likely to be correlated when patients relapsed (r = .53) than when they did not relapse (r = .12). Results suggest that bipolar patients who show increased signs of residual symptomatology during family transactions during the post-hospital period are at increased relapse risk. The data also suggest that relatives of relapsing patients cope with these symptoms by increasing both positive and negative affective behaviors. Moreover, a bidirectional, interactional relationship between patients' symptoms and relatives' coping style seems to capture best the role of the family in predicting relapse in bipolar disorder.     

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.     

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.     

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.     

Carers' attributions about positive events in psychosis relate to expressed emotion

Background

Relapse is increased in people with psychosis who live with carers with high expressed emotion (EE). Attributional style has been used to understand EE at a psychological level. Previous studies have investigated carer appraisals for negative events in the patient's life. We therefore aimed to examine spontaneous carer attributions for both negative and positive events. Further, we distinguished between high EE based on critical comments, and that based on emotional-overinvolvement.

Method

Audiotapes of the Camberwell Family Interview (CFI) (N = 70) were rated using the Leeds Attributional Coding System (LACS). Raters were blind to previous ratings of EE.

Results

In our sample, low EE carers made significantly more attributions about positive events, and less about negative events than high EE carers. This is because criticism, but not overinvolvement, was strongly associated with responsibility attributions for negative events, while overinvolvement, but not criticism, was inversely associated with responsibility attributions for positive events.

Conclusion

Carers' attributions for both positive and negative events may be a useful target for improving family interventions in psychosis.     

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.     

Expressed emotion and attributions in the carers of patients with Alzheimer's disease: the effect on carer burden

Burden of care, expressed emotion (EE), causal attributions, and salivary cortisol were assessed in 100 carers of patients with Alzheimer's disease. Forty-one carers were rated high EE, which was associated with higher scores of carer distress and strain, and greater reports of noncognitive features in the patient, but not with cortisol levels. High EE carers made more attributions personal to, and controllable by, the patient for negative events. Critical carers made more attributions of the patient's behavior that was idiosyncratic. Warmth toward the patient was associated with the opposite of this pattern. Overinvolved carers made attributions of the patient's behavior to causes external to the patient and internal to themselves. Cortisol levels were associated with self-reports of strain and distress.     

Testing a conceptual model of patient and family predictors of obsessive compulsive disorder (OCD) symptoms

Path analysis was used to test a model linking family member's attributions, criticism, hostility, emotional overinvolvement (EOI) that focused on intrusiveness, and family accommodation to severity of obsessive compulsive symptoms. This study draws upon previous expressed emotion (EE) research by including separate components of EE assessed in relatives and patients, as well as family accommodation measures to build a model of family influences on OCD symptoms. Measures of patient- and relative-perceived criticism, family accommodation, EOI intrusiveness and OCD symptom severity were collected on a single occasion from 50 patients and 50 relatives whom the patient had daily contact with. Novel self-report scales for the three EE components of criticism, hostility and EOI derived from existing instruments showed good to excellent internal consistency. Confirmatory path analyses were used to demonstrate that the data provided an adequate fit to the hypothesized path model. The patient-rated data suggested that patients who perceived their relatives as either critical or hostile were likely to have more severe OCD symptoms. For relative-rated EE, hostility proved to be a better determinant than criticism in the path model. Implications of this model for interventions and for future research are discussed. The measures employed may prove to be a cost-effective alternative to the labor intensive Camberwell Family Interview.     

An Acceptance-Based Psychoeducation Intervention to Reduce Expressed Emotion in Relatives of Bipolar Patients

Expressed emotion (EE) is a robust predictor of outcome in bipolar disorder. Despite decades of research, interventions to reduce EE levels have had only modest effects. This study used an expanded model of EE to develop an intervention. Research has demonstrated a strong link between attributions and EE in families of patients with psychiatric disorders. There is also substantial research to suggest that anger can drive blaming attributions. Combining these ideas, this study built on previous psychoeducation interventions through the addition of an acceptance component designed to decrease anger and blaming attributions among family members of those with bipolar disorder. Twenty-eight family members attended a 1-day or 2-evening multifamily group workshop and completed a follow-up assessment 1 week later. At follow-up, participants demonstrated more knowledge about bipolar disorder. Anger, blaming attributions, and number of criticisms remained unchanged. Results of this study are consistent with others in that it is difficult to change EE. Implications for future clinical research in this area are addressed.     

Is Expressed Emotion an Index of a Transactional Process? I. Parents' Affective Style

The degree to which expressed emotion (EE) attitudes in key relatives reflect ongoing transactional processes in families is a topic of controversy. The associations between EE attitudes, as measured during an acute hospitalization (using the Camberwell Family Interview) and during the aftercare period (using 5-minute speech samples), and interactional behavior in parents of recent-onset schizophrenics (this article) and in patients themselves (second article), were investigated. In the first study, EE attitudes manifested by parents during the aftercare period were stronger correlates of their interactional behaviors during the aftercare period than were EE attitudes measured during the inpatient period, despite the frequent correspondence between the two EE measures. The pattern of attitudes shown between the inpatient and outpatient periods also predicted transactional styles in parents during the outpatient period, findings not accounted for by clinical attributes of patients. When high-EE attitudes persist during the aftercare period and are reflected in transactional behaviors, the risk for subsequent patient relapse may be enhanced.     

Predictors of relapse in unipolar depressives: expressed emotion, marital distress, and perceived criticism

The predictive validity of expressed emotion (EE) and two conceptually related but more easily measured alternatives--marital distress, and patients' perceptions of criticism from spouses--were examined in a sample of hospitalized unipolar depressives. All three psychosocial variables were significantly associated with 9-month relapse rates. Expressed emotion and marital distress predicted the same proportion of variance in patients' outcomes. The single best predictor of relapse, however, was a patient's response to the question "How critical is your spouse of you?" Patients who relapsed rated their spouses as significantly more critical than did patients who remained well. Alone, the perceived criticism variable accounted for more of the variance in relapse rates than that explained by EE and marital distress combined. The results suggest that asking depressed patients how critical they believe their relatives are may facilitate the identification of individuals at high risk for relapse subsequent to hospital discharge.     

Expressed Emotion In The Narrative Context of Family Photographs

This study aims to elucidate cognitive and contextual aspects of the EE (Expressed Emotion) concept. The EE levels of both parents of two first admission psychotic patients were rated from the Five Minute Speech Sample (FMSS), and the emotional responses were further analyzed in narratives of family photographs. The attribution model was found to provide an explanatory framework for understanding relatives' expressed emotions (EE) toward a family member suffering from psychotic disturbances. Four case reports indicated that family photographs induced parents to create narratives in which emotions, attributions, and strategies for coping with stressful aspects of the illness came forward as intertwined phenomena. The method can offer more comprehensive data for intervention strategies aiming to alter the prevailing atmosphere and interaction patterns within the high EE family.     

A diathesis-stress conceptualization of expressed emotion and clinical outcome

A sizeable body of research has demonstrated that expressed emotion (EE) predicts clinical relapse in a number of distinct psychiatric disorders. These findings have provided the impetus for the development of interventions that attempt to reduce patients' relapse rates by modifying aspects of the family environment believed to be associated with high levels of EE. Despite the efficacy of these treatments, however, we know little about how EE develops in relatives of psychiatric patients or about the mechanisms through which high EE leads to relapse. Moreover, there is not a coherent theory that attempts to integrate findings concerning the impact of high EE on relapse in different disorders. The purpose of this article is to elucidate a diathesis-stress conceptualization of EE to explain both the development and manifestation of high EE in relatives of disordered patients and the impact of high EE on the course of patients' disorders. In this context, we use a diathesis-stress perspective to examine why EE predicts symptom relapse and poor clinical outcome in schizophrenia, depressive disorders, and borderline personality disorder. We conclude by discussing treatment implications of the diathesis-stress perspective and by outlining what we believe are fruitful directions for future research.