Expressed emotion, communication deviance, and culture in families of patients with schizophrenia: a review of the literature

The aim of this article is to critically review the literature on expressed emotion (EE), communication deviance (CD), and culture in families of patients with schizophrenia. There is growing evidence that EE and CD are highly linked. Yet the two constructs together predict the development of schizophrenia and the associated symptoms better than either construct alone. In this article, the authors review data indicating that both the expression and the levels of high EE and CD vary by ethnicity. It may be especially difficult for family members to communicate coherently and in a less critical manner when focusing on patients' inability to sustain particular cultural norms and values that are endorsed by their family and ethnic background. The authors propose that more attention to the role of culture in EE and CD and greater focus on the proper assessment of these variables would further enhance our understanding of these constructs.     

Contradictions of emotion in schizophrenia

This paper considers contradictory features of emotional or affective experience and expression in schizophrenia in light of the “Kretschmerian paradox”—the fact that schizophrenia-spectrum patients can simultaneously experience both exaggerated and diminished levels of affective response. An attempt is made to explain the paradox and explore its implications. Recent research on emotion in schizophrenia is reviewed, including subjective reports, psychophysiological measures of arousal or activation, and behavioural measures, focusing on flat-affect and negative-symptom patients. After discussing relevant concepts and vocabulary of emotion (“affect”, “emotion”, “mood”, “feelings”, the “passions”), the need for a phenomenological approach focusing on subjective experience is proposed. Four modes of nonparanoid experience in schizophrenia are discussed: Bodily Alienation, Disengagement, Unworlding, and Subjectivisation. Each mode involves withdrawal from functional contexts—temporal, practical, and interpersonal—normally associated with emotional reactivity and expression; each may be accompanied by forms of non-emotional affectivity no less intense than the emotions they replace. Possible relationships between psychophysiological measures, expressive behaviour, and subjective emotional or affective response are considered.     

Ethnicity, expressed emotion, attributions, and course of schizophrenia: family warmth matters

The authors examined the role of family factors and the course of schizophrenia by carrying out additional assessments and analyses in 2 previously published studies of Mexican American and Anglo American patients and families. The authors found partial support for an attributional model of relapse for families who are low in emotional overinvolvement. Attributions of control, criticism, and warmth together marginally predicted relapse. The data also indicated that for Mexican Americans, family warmth is a significant protective factor, whereas for Anglo Americans, family criticism is a significant risk factor. These findings suggest that the sociocultural context shapes the pathways by which family processes are related to the course of illness. Moreover, the warmth findings suggest that families may contribute to preventing relapse.     

Expressed emotion in depressed patients and their partners.

This study was designed to assess the expressed emotion (EE) status in the spouses of depressed patients and the patients themselves, to relate the EE status to the severity of depression as measured by the Beck Depression Inventory (BDI), and to compare the prevalence of high EE between the target and control group. Seventeen depressed patients and their spouses, and 20 control couples participated in the study. The Five-Minute Speech Sample was used to assess the EE status. High EE was significantly more common in spouses of depressed patients and the patients themselves than in controls. There was a significant relationship between the EE status of the patients and their spouses. High EE in the patient and in the spouse corresponded significantly with a high BDI score of the patient. These findings underline the importance that in EE research the patients' EE status as well as their present mental health state must also be taken into account.     

Expressed emotion and Milan systemic intervention: a pilot study on families of people with a diagnosis of schizophrenia

This article presents the results of a pilot study carried out on families of people with a diagnosis of schizophrenia (high‐frequency users of psychiatric services) using a standardized version of systemic family intervention based on the Milan Approach (‘Circular Interview’). We used expressed emotion (EE) to compare and assess two homogeneous samples of families, a treatment group (n = 10) and a control group (n = 8). We found that families participating in circular interviews showed a reduction in criticism, while 30% of their members with a diagnosis of schizophrenia relapsed. Families not receiving treatment showed no changes in EE levels, while 62.5% of their members with a diagnosis of schizophrenia relapsed. Although the difference in relapse rates is not statistically significant, these results justify further studies on the use of nondirective systemic intervention with families of people with a diagnosis of schizophrenia.     

Sex differences in the time course of emotion

Conventional wisdom holds that women are more "emotional" than men. However, research evidence suggests that sex differences in emotion are considerably more complex. The authors tested hypotheses about sex differences in the engagement of the approach and avoidance motivational systems thought to underpin emotional responses. The authors measured reported emotional experience and startle response magnitude both during the presentation and after the offset of emotional stimuli that engage these motivational systems to assess whether men and women differ in their patterns of immediate response to emotional stimuli and in their patterns of recovery from these responses. Our findings indicated that women were more experientially reactive to negative, but not positive, emotional pictures compared to men, and that women scored higher than men on measure of aversive motivational system sensitivity. Although both men and women exhibited potentiation of the startle response during the presentation of negative pictures relative to neutral pictures, only women continued to show this relative potentiation during the recovery period, indicating that women were continuing to engage the aversive motivational system after the offset of negative emotional pictures.     

Anhedonia and the experience of emotion in individuals with schizophrenia

Research shows that individuals with schizophrenia report symptoms of anhedonia when assessed by interview or questionnaire. However, when presented with emotional stimuli, they report emotional experiences that are similar to those of control participants. The authors hypothesized that deficits in working memory and episodic memory contribute to such discrepancies. They administered measures of working and episodic memory, self-report anhedonia questionnaires, and several types of emotional stimuli to 49 individuals with schizophrenia and 47 control participants. All participants reported experiencing similar amounts of pleasant-unpleasant emotion (valence) in response to stimuli, but individuals with schizophrenia reported experiencing less arousal for negative stimuli. Individuals with schizophrenia also reported greater social and physical anhedonia on a traditional anhedonia questionnaire. Disturbances in working memory moderated the relationship between physical anhedonia and participants' emotional experience of positive stimuli.     

Expressed emotion and reciprocal affective relationships in families of disturbed adolescents

Relatives' expressed emotion (EE) is a known risk factor for relapse among recovering psychiatric patients. Recent research has focused on the behavioral correlates of EE, seeking better understanding of the family processes associated with this important variable. The present study used sequence analysis to explore interactions of high-EE and low-EE parent-child dyads in a sample of disturbed adolescents. High-EE mother-child interactions were characterized by bidirectional influence, and, in contrast to adolescents in low-EE dyads, adolescents in high-EE dyads had an oppositional style of responding. In Low-EE mother-child interactions, the adolescents showed more temporal consistency (stability) of affect than their high-EE counterparts. Overall, the results suggest that high-EE mother-child dyads constitute more tightly joined emotional systems than low-EE dyads. Consequently, interventions designed to reduce this connectedness might also reduce the risk of adolescent psychiatric problems.     

Expressed emotion in families of children and adults with intellectual disabilities

Expressed emotion (EE) is a measure of the affective relationship between two people characterized by criticism, hostility, and emotionally over-involved attitudes. Outside of the field of intellectual disabilities, there has been considerable interest in EE as an environmental marker that explains variance in the severity and/or course of a number of psychiatric disorders. Researchers have also studied EE in parents and found strong associations with children's behavior problems. In this review, we focus on the data from 11 published studies of EE in families of children and adults with intellectual disabilities. We conclude that there is evidence for the presence of high EE in some families, and that this alone should concern researchers and clinicians and set an agenda for considerable future research effort. We also note a lack of attention to the measurement of EE in intellectual disability. In terms of the existing evidence base, we suggest that there is support for the hypothesis that behavior problems in children and adults with intellectual disabilities may be related to high EE in parents, and a small amount of data predicting over time support the putative causal effect of high EE on maintaining or exacerbating behavior problems. Given that EE is perhaps best conceptualized as the result of an interaction between caregivers and those cared for, there is a need to explore interventions that may help to remediate high EE within families. It is also important to understand from this position that EE may be a normative part of the experience of caring for someone under very stressful circumstances and not something for which families are blamed. Other future research priorities and some implications for practice are also discussed.     

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.     

The sociocultural conceptualisations of schizophrenia and patterns of help seeking in south-east Nigeria

Socioculturally influenced interpretations of mental illness play decisive roles on the time and choice of treatment. These often result in significant delays before patients present at the psychiatric services, with consequent worsening of the prognosis. The aim was to assess the association between sociocultural factors, choice of treatment and treatment delay among patients with schizophrenia. A cross-sectional study of 360 patients with schizophrenia, without previous contact with any statutory psychiatric services, was done. Of this, 75.8% of the participants had visited traditional/faith healers as the first treatment option and have attributed schizophrenia to magico-supernatural causation, despite 70.0% of the participants being educated, while 24.2% of them believed in the natural causation of the illness and presented early to psychiatric hospital. There is a need for community-based psychiatric services that would have mental health education as one of their core mandates; and collaborations with traditional and faith-based healers aimed to reduce delay in their facilities.     

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.     

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.     

The sociocultural movement in psychology,the role of theories in sociocultural inquiries,and the theory of sociocultural models

This special issue presents the theory of sociocultural models (TSCM) and its applications in diverse areas of psychology, including education, health care, clinical practice, gender relations, and general research. As many theories already exist in the social sciences, some readers may ask: “Why do cross‐cultural, cultural, and indigenous psychologists need another theory?” This question is comprised of two aspects: culture/cultural and theory/theoretical. Therefore, to answer it, it is important to clarify both issues. The first relates to cultural and its relation to psychological. The second, theory, considers its relation to cultural and psychological. These issues have long‐range implications for all culture and psychology disciplines as they pose many questions: What role does culture play in the mental functioning of people? How is culture constituted? Is cultural related to social? Does people’s mental functioning exert reciprocal influences on their cultural and social functioning? While working toward answering these questions, researchers quickly determine that more questions arise: What role should theories play in answering these questions? What constitutes theory in culture and psychology disciplines? How should such a theory (or such theories) address the triad of cultural, social, and mental? Consequently, in an effort to provide an overview of the TSCM and to begin to answer these questions, this introduction consists of two parts. The first part addresses the sociocultural turn in modern psychology; this part discusses its implications for research in culture and psychology disciplines. The second segment examines the topic of the theoretical backgrounds of cultural and cross‐cultural research and connects the philosophical paradigms of interpretivism and realism with the theory of sociocultural models. This introduction concludes with a brief overview of the articles included in this issue.     

The time course of positive and negative emotion in dysphoria

Prior research has demonstrated attenuated reactivity to positive stimuli among depressed and dysphoric individuals, and inconsistent evidence regarding attenuated reactivity to negative stimuli. However, such research has measured experiential reactivity to emotion stimuli in one static moment, which may obscure important information regarding the time course and dynamics of emotion. The current study employed continuous measurement of experiential emotion during and following the presentation of emotion eliciting film clips. Results revealed that dysphoric individuals (n = 16), as compared to nondysphoric controls (n = 31), were equally responsive to positive and negative film clips in terms of peak reactivity during and following the clip. The most striking difference between groups was that dysphoric individuals showed a shortened time course of positive emotion. These emotion dynamics suggest that perhaps the most important aspect of positive emotion regulation in the context of depressed mood is not the inability to initially react to a positive experience, but rather the inability to maintain positive emotion. Possible underlying mechanisms of positive emotion regulation are discussed, and implications for intervention are highlighted.     

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.     

Emotional responding in depression: Distinctions in the time course of emotion

The current studies were designed to investigate if the emotion context insensitivity hypothesis (ECI; Rottenberg & Gotlib, 2004) is applicable across the time course of emotion. Recent affective science research has pointed to the importance of considering anticipation and maintenance of emotion. In the current studies, we assessed emotion responses among college students with depression symptoms in anticipation of, during, and after an emotional picture using the emotion modulated startle paradigm. People with and without depression symptoms did not differ in blink magnitude in anticipation of emotional pictures suggesting that some anticipatory processes may not be impaired by depression symptoms. In contrast, individuals with depression symptoms did not exhibit blink magnitudes that varied by valence, either during viewing or after the pictures were removed from view. These findings suggest that ECI is relevant not only for those diagnosed with major depressive disorder, but also for people with depression symptoms that may not cross the diagnostic threshold. These data also point to the importance of considering the time course of emotion to better understand emotional deficits in individuals with differing levels of depression symptoms. Identifying where emotion goes awry across the time course of emotion can help inform treatment development.     

Emotional responding in depression: Distinctions in the time course of emotion

The current studies were designed to investigate if the emotion context insensitivity hypothesis (ECI; Rottenberg & Gotlib, 2004) is applicable across the time course of emotion. Recent affective science research has pointed to the importance of considering anticipation and maintenance of emotion. In the current studies, we assessed emotion responses among college students with depression symptoms in anticipation of, during, and after an emotional picture using the emotion modulated startle paradigm. People with and without depression symptoms did not differ in blink magnitude in anticipation of emotional pictures suggesting that some anticipatory processes may not be impaired by depression symptoms. In contrast, individuals with depression symptoms did not exhibit blink magnitudes that varied by valence, either during viewing or after the pictures were removed from view. These findings suggest that ECI is relevant not only for those diagnosed with major depressive disorder, but also for people with depression symptoms that may not cross the diagnostic threshold. These data also point to the importance of considering the time course of emotion to better understand emotional deficits in individuals with differing levels of depression symptoms. Identifying where emotion goes awry across the time course of emotion can help inform treatment development.