Abstract
Introduction: High Expressed Emotion (EE) is a well-established familial predictor of increased likelihood of relapse in schizophrenia. EΕ is mainly assessed through the semi-structured Camberwell Family Interview (CFI) given by a relative talking about the patient with schizophrenia. It consists of five scales, the scale of critical comments (CC), Hostility, Emotional Over-involvement (EOI), Warmth and Positive Remarks (PR). From the evaluation of the scores of the first three of the above scales, the relative can be characterized as high or low EE. The scales of Warmth and PR, which are the positive emotional elements of the EE, do not participate in the final evaluation of the EE. The scale of critical comments is included in the EE evaluation only as an absolute number and not as a content, excluding important information about relatives' relationships with patients within the family. Moreover, causal attributions seem to play an important role in family relationships, i.e., what d ...
Introduction: High Expressed Emotion (EE) is a well-established familial predictor of increased likelihood of relapse in schizophrenia. EΕ is mainly assessed through the semi-structured Camberwell Family Interview (CFI) given by a relative talking about the patient with schizophrenia. It consists of five scales, the scale of critical comments (CC), Hostility, Emotional Over-involvement (EOI), Warmth and Positive Remarks (PR). From the evaluation of the scores of the first three of the above scales, the relative can be characterized as high or low EE. The scales of Warmth and PR, which are the positive emotional elements of the EE, do not participate in the final evaluation of the EE. The scale of critical comments is included in the EE evaluation only as an absolute number and not as a content, excluding important information about relatives' relationships with patients within the family. Moreover, causal attributions seem to play an important role in family relationships, i.e., what deeper reason does the relative consider as the cause of the behavior and symptoms of the patient with schizophrenia. In Greece, the only previous literature on EE assessed with the CFI interview is the research of Mavreas V. et al., in 1992, while the Warmth of relatives has not been measured and related to other variables, and the causal attributions of relatives have never been evaluated before. Finally, the area of everyday life in which relatives express more critical comments during the CFI interview is not yet analyzed in schizophrenia literature. Aim: The aim of this research is:1. Assessment of the EE of relatives of people with schizophrenia in the Greek population and comparison with previous Greek and international studies.2. Search for relations among EE and Warmth with variables such as demographic characteristics, coping strategies, religiosity-spirituality and well-being.3. Analysis of the characteristics and content of relatives' critical comments.4. Analysis of the relatives' causal attributions for symptoms, behaviors and problems arising from the patient. Method: In this study, EE was assessed in a sample of 48 key relatives of people with schizophrenia using the CFI interview. In addition, relatives completed self-administered questionnaires on coping strategies (brief-COPE), religiosity/spirituality (System of Beliefs Inventory SBI-15R), quality of life (Well-Being Index WHO-5) as well as a demographic questionnaire. Moreover, the LACS (Leeds Attributional Coding System) was used to find the causes of the patients' symptoms and behaviors given by the relatives during the CFI interview. Results: The majority of the sample relatives were of high EE (64.6% high EE, 35.4% low EE) and the predominant type of high EE being the high EOI (22.9%). Relatives who expressed a higher level of Warmth were found to make fewer CC (5.2 ± 4.6 vs. 8.4 ± 4.6, p = 0.009) and have, on average, higher EOI scores (3.2 ± 1.0 vs. 1.9 ± 1.1, p = 0.002) than those who expressed no or very little Warmth. High EE was found to be associated with having fewer family members (p = 0.035), while relatives with a higher level of education expressed less Warmth (p = 0.007). Relatives with a low level of Warmth had higher maladaptive coping scores and tended to score worse for their overall wellbeing in comparison to relatives who showed a higher level of Warmth (28.4 ± 5.0 vs. 24.1 ± 5.2, p = 0.006 and 39.1 ± 20.4 vs. 51.3 ± 22.0, p = 0.073, respectively). Relatives with high EE have no statistically significant differences in religiosity/spirituality from relatives with low EE (21.0± 10.9 vs. 25.1 ± 12.3, p = 0.185) and relatives with low levels of Warmth have no statistically significant differences in religiosity /spirituality from relatives with high levels of Warmth (19.6 ± 12.3 vs. 23.6 ± 11.0, p = 0.340).In relation to the content of critical comment that was made, the comparison between high and low EE relatives showed nagging (35.5% vs. 5.9%, p= 0.035), sleep (25.8% vs. 0%, p= 0.038), violence (38.7% vs. 0%, p= 0.004), household tasks (38.7% vs. 0%, p= 0.004) and interpersonal relations (41.9% vs. 11.8%, p= 0.031) were the most frequent. Males made more statistically significant comments on the management compared to females (43.8% vs. 12.5%, p= 0.027). Males made statistically less comments for patient΄s appetite (6.3% vs. 34.4%, p= 0.040) compared to females. By categorizing the content of critical comments, 70.8% of relatives made critical comments on everyday life tasks and 68.8% on negative behaviors-violence. Relatives of high EE in criticism and hostility (CC+Hostility) compared with the other high EE categories made more critical comments on negative symptoms-depression (100% vs. 36.0%, p= 0.007). High EE relatives on EOI, compared to other high EE relatives made less critical comments concerning negative symptoms-depression (0% vs. 6.2%, p= 0.002) and negative behavior-violence (50.0% vs. 87.0%, p= 0.053). In relation to causal attributions, the high EE critical (CC) relatives attribute the behavior of the patients statistically significantly in personal (0.74±0.21 vs. 0.50±0.09, p= 0.020) and controllable causes (0.73±0.21 vs. 0.50±0.10, p= 0.012) compared to high EE on EOI relatives. In the relative’s descriptions that were coded as both critical comments according to Expressed Emotion and as containing causal attributions according to LACS, it seemed that these descriptions attribute the patient behavior in personal (r=0.559, p<0.001) and controllable causes (r=0.534, p<0.001). In descriptions that were rated as containing EOI in EE, the causal attributions were mainly attributed to stable (r=0.395, p=0.006) or global (r=0.378, p=0.009) causes. Conclusion: In our study, relatives of people with schizophrenia have a higher percentage of high EE and are more critical and less Emotionally Overinvolved compared to the previous Greek research of 1992, which may reflect the change in Greek society and family in recent years. Moreover, first-degree relatives (mainly parents) are more often found to have high EE compared to second-degree relatives (siblings) in Greece. Relatives' low Warmth is related to maladaptive coping and lower levels of the relative's well-being. Relatives that are high EE Critical (CC) attribute the patients' behavior to individual and patient-controlled causes. Relatives seem to be more critical in relation to the management of everyday life and disruption of the calm family emotional climate than to the symptoms of schizophrenia. Relatives' critical comments contain information about their EE, their well-being and their causal attributions of symptoms and therefore should be considered both in psychosocial family interventions and in treatment by the responsible multidisciplinary team. The results of the present research could be used in psychoeducational interventions which can be customized with the guidance of the analysis of relatives' criticism. Interventions should include siblings of patients, should fill the gap in relatives' knowledge to change causal attributions and set the increase of Warmth as a stand-alone goal, improving relative’s coping and well-being. This research highlights the need for more effective information about schizophrenia from mental health services and therapists.
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