Alternative measures of expressed emotion: A methodological and cautionary note

An intergenerational study of parental bonding on perceptions of parental and spousal criticism and marital relationship quality in Singapore

Criticism is a form of interpersonal social rejection and destructive conflict behavior which has been associated with poor relationship outcomes in both parent-child and marital relationships. However, the role of the individual's perceptions of parental and spousal criticism in influencing the perceptions of criticism of other members in the family unit has not been examined. This study investigated the associations between parental bonding and perceptions of parental and spousal criticism across generations in Singapore. In all, 134 Singaporean married parent dyads (G2) and one child (G3) of each dyad were recruited. G2 parent participants completed the Perceived Criticism measure for their parents (G1) and spouses, the Parental Bonding Instrument and the Quality of Marriage Index. G3 children participants completed the Perceived Criticism measure for their parents (G2). Path analysis found that G2 perceptions of parental bonding were significant predictors of G2's perceptions of G1 parental criticism, which significantly predicted both G2's perceptions of spousal criticism and G3's perceptions of G2 parental criticism. Perceptions of spousal criticism were also found to predict marital relationship quality in G2 participants. Findings highlight the intergenerational transmission of perceptions of criticism across relationships in the family unit, providing support that parenting practices and communication patterns in one generation can predict those in the next generation in the Singaporean context. Future studies can look to replicate the findings in other cultures and include further investigations into sibling relationships as well.

Negative emotional reactions to criticism: Perceived criticism and source affects extent of hurt and relational distancing

Criticism is commonly perceived as hurtful and individuals may respond differently to criticism originating from different sources. However, the influence of an individual’s perception of criticism in their social relationships on negative emotional reactions to criticism has not been examined across different relational contexts. The present study investigated the influence of perceived criticism and relational contexts–mother, father, romantic partner, and workplace supervisor–on the feelings of hurt and relational distancing experienced upon receiving criticism. Participants (N = 178) completed the Perceived Criticism Measure and read vignettes describing scenarios of personally directed criticism in the four relational contexts. Significant main effects of perceived criticism and source were found on levels of relational distancing. Participants who perceived their relational partner to be more critical experienced greater distancing upon receiving criticism from them. Greater relational distancing was experienced for criticism received from workplace supervisors compared to mothers, fathers and romantic partners. Results indicate that emotional reactions and relationship outcomes in response to criticism can differ based on individual differences and relational context, suggesting their role in relationship maintenance and development of psychopathology.

A cross-cultural study of the effect of parental bonding on the perception and response to criticism in Singapore, Italy and USA

Parents play a primary and crucial role in emotional socialisation processes in children where individuals learn the expression, understanding and regulation of emotions. Parenting practices and dimensions of the parent-child relationship have been associated with social and emotional processes in children. As criticism involves negative emotional reactions and emotion regulation, the parent-child relationship is likely to influence an individual's perception and response to criticism. Hence, the present study investigated the relationship of parental bonding and the perception and response to criticism in three different countries-Singapore, Italy and USA. Adult participants (n = 444) completed the Parental Bonding Inventory (PBI) and measures of criticism. Parental care, overprotection and country were found to be significant predictors of a tendency to perceive criticism as destructive. Higher levels of parental care predicted a lower tendency to perceive criticism as destructive while higher levels of parental overprotection predicted a higher tendency to perceive criticism as destructive. US American participants were found to have a significantly higher tendency to perceive criticism as destructive compared to Italian and Singaporean participants. The findings align with past research on the role of the parent-child relationship in the socio-emotional development of children as well as providing insight into a specific aspect in social interaction; perception and response to criticism, being affected. Future studies can look to investigate this relationship further in different countries in light of cultural variation in parenting styles and emotion experience, expression and regulation.

Disapproval from romantic partners, friends and parents: Source of criticism regulates prefrontal cortex activity

The prevalence of criticism in everyday social situations, and its empirically demonstrated association with psychopathology, highlight the importance of understanding neural mechanisms underlying the perception and response of individuals to criticism. However, neuroimaging studies to date have been limited largely to maternal criticism. The present study aims to investigate neural responses to observing criticism occurring in the context of three different relationship types: romantic partners, friends, and parents-from a third-party perspective. 49 participants were recruited and asked to rate the perceived criticism for these relationships. Functional near-infrared spectroscopy was used to measure changes in oxygenated haemoglobin levels in the prefrontal cortex when participants read vignettes describing three different scenarios of criticism. Participants were randomly assigned to 3 groups where the given description of the relationship of the protagonist to the source of criticism for each vignette was randomised. A significant interaction between relationship type and perceived criticism ratings for mothers was found in the dorsolateral prefrontal cortex. Compared to low perceived criticism, high perceived criticism individuals showed increased activation reading vignettes describing criticism from romantic partners and parents but decreased activation for those from friends. Findings contribute to understanding neural responses to criticism as observed from a third-party perspective. Future studies can look into differentiating neural responses of personalised experiences of criticism and third-party observations.

Integrity of Literature on Expressed Emotion and Relapse in Patients with Schizophrenia Verified by a p-Curve Analysis

There is growing concern that much published research may have questionable validity due to phenomena such as publication bias and p-hacking. Within the psychiatric literature, the construct of expressed emotion (EE) is widely assumed to be a reliable predictor of relapse across a range of mental illnesses. EE is an index of the family climate, measuring how critical, hostile, and overinvolved a family member is toward a mentally ill patient. No study to date has examined the evidential value of this body of research as a whole. That is to say, although many studies have shown a link between EE and symptom relapse, the integrity of the literature from which this claim is derived has not been tested. In an effort to confirm the integrity of the literature of EE predicting psychiatric relapse in patients with schizophrenia, we conducted a p-curve analysis on all known studies examining EE (using the Camberwell Family Interview) to predict psychiatric relapse over a 9- to 12-month follow-up period. Results suggest that the body of literature on EE is unbiased and has integrity, as there was a significant right skew of p-values, a nonsignificant left skew of p-values, and a nonsignificant test of flatness. We conclude that EE is a robust and valuable predictor of symptom relapse in schizophrenia.

Expressed Emotion in relatives of persons with dementia: a systematic review and meta-analysis

OBJECTIVES

Expressed Emotion (EE) refers to a number of key aspects of interpersonal relationships which have been shown to relate to outcomes in relatives of people with health conditions.

DESIGN

A systematic review and meta-analysis of EE and outcomes in relatives of persons with dementia is reported. Potential research studies were identified via a search of three electronic databases; PsychINFO, MEDLINE and the Web of Science between 1960 and 2015.

RESULTS

We reviewed 12 studies investigating correlations between EE and well-being in relatives of patients with dementia. Factors hypothesised to influence EE including attributions, social support, coping strategies and relationship quality were also reviewed.

CONCLUSION

High-EE relatives were found to have increased levels of burden (Z = 6.967, P < 0.001) and greater levels of depression (Z = 5.842, P < 0.001). Compared to low-EE relatives, high-EE relatives were more likely to attribute the patient's problems to factors that were personal to and controllable by the patient. Relatives with less social support, inefficient coping strategies and a poor relationship with the patients, were more likely to be classified as high-EE.

Deeper into schizotypy and motor performance: Investigating the nature of motor control in a non-psychiatric sample

Numerous studies have demonstrated that motor control deficits are characteristic of patients diagnosed with schizophrenia and those at-risk for the development of the disorder. Recent advances in the quantification of motor dysfunction have confirmed this, but these methods fail to consider an important aspect of subject performance: the qualitative nature of their psychomotor dyscontrol. We report on a novel technique used to quantify the qualitative nature of psychomotor performance and its relation to schizotypy. Control (n = 35) and schizotypic subjects (n = 47) completed a line-drawing task that yields metrics for psychomotor control and predominant frequency. Schizotypes evidenced greater psychomotor dyscontrol and lower predominant frequencies than controls. These results are interpreted as evidence of reduced visual-motor integration, self-monitoring capacity, or adherence to basic motor principles in schizotypes. The potential use of these metrics as putative endophenotypes for the liability for schizophrenia and the implications of these findings for the relationship between schizophrenia and schizotypy are discussed.

The prognostic role of perceived criticism, medication adherence and family knowledge in bipolar disorders

BACKGROUND

In schizophrenia, high levels of critical comments by significant others are associated with early relapse, especially if medication adherence is sub-optimal. Levels of criticism may be influenced by family knowledge about both the disorder and its treatment. No study has explored whether this combination factors influence outcome in adults with bipolar disorders.

METHODS

Medication adherence was assessed in 81 individuals with bipolar disorder of whom 75 rated perceived criticism by an identified 'significant other' as well as their own perceived sensitivity. 33 (of the 75) had a close family member who agreed to completed an assessment of their knowledge and understanding of bipolar disorders. Psychiatric admissions were then recorded prospectively over 12 months.

RESULTS

Perceived criticism and medication adherence were significant predictors of admission. In the patient-family member dyads (n=33), the odds ratio (OR) for admission was 3.3 (95% confidence intervals 1.3-8.6) in individuals with low levels of medication adherence, high perceived criticism, and a family member with poor knowledge and understanding.

LIMITATIONS

The small sub-sample of patient-family member dyads means those findings require replication. Sensitivity to criticism by professional caregivers may not equate to that by relatives.

CONCLUSIONS

Perceived criticism may be a simple but robust clinical predictor of relapse in mood disorders. High levels of perceived criticism, poor understanding of bipolar disorder by a significant other, and sub-optimal treatment adherence are risk factors for hospitalization in adults with bipolar disorders that are potentially modifiable through the use of strategic psychosocial interventions.

Affective and neural reactivity to criticism in individuals high and low on perceived criticism

People who have remitted from depression are at increased risk for relapse if they rate their relatives as being critical of them on a simple self-report measure of Perceived Criticism (PC). To explore neural mechanisms associated with this we used functional magnetic resonance imaging (fMRI) to examine how people with different levels of PC responded to hearing criticism from their own mothers. To maximize variability in affective reactivity, depressed, recovered depressed, and healthy control participants (n = 33) were classified as high or low in PC based on a median split. They were then exposed to personally-relevant critical and praising comments from their mothers. Perceived Criticism levels were unrelated to depression status and to negative mood change after hearing criticism. However, compared to low PC participants, those who scored high on PC showed differential activation in a network of regions associated with emotion reactivity and regulation, including increased amygdala activity and decreased reactions in prefrontal regulatory regions when they heard criticism. This was not the case for praise. Criticism may be a risk factor for relapse because it helps to “train” pathways characteristic of depressive information processing. The Perceived Criticism measure may help identify people who are more susceptible to this vulnerability.

Predictive validity of the Family Attitude Scale in people with psychosis

Expressed Emotion (EE) strongly predicts relapse in mental disorders, but there remains a need to develop and refine brief, self-report measures. This article describes two studies testing the validity of a self-report measure of criticism or burden, the Family Attitude Scale (FAS), in relatives of patients with psychosis. Study 1 had 54 families of patients with psychosis and a substance use disorder, while Study 2 had 61 families of patients at an early psychotic episode. In Study 1, a consensus FAS was obtained; in Study 2 separate parental scores were used. The FAS was positively associated with EE, and with relationship negativity. Associations with negative caregiving experiences or stress were restricted to maternal or consensual FAS ratings. FAS scores predicted relapse in both studies, although prediction at the optimal cutoff (>or=60) only reached statistical significance in Study 2, and time to relapse was only predicted by the FAS in Study 1. Prediction of relapse from the CFI was stronger, and the FAS did not add to that prediction. Results supported the utility of the FAS, but confirmed the pre-eminence of the CFI as a household-related predictor of relapse.

Measuring expressed emotion: an evaluation of the shortcuts

The construct of expressed emotion (EE) is a highly reliable and valid predictor of poor clinical outcomes in patients with major psychopathology. Patients are at early risk for relapse if they live with family members who are classified as high in EE. Conventionally, EE is assessed with the Camberwell Family Interview (CFI), a semistructured interview that is conducted with the patient's key relatives. Unfortunately, training in the CFI is difficult to obtain. The CFI is also time-consuming to administer and labor intensive to rate. In this article, the authors discuss alternative ways of assessing EE. They also evaluate the predictive validity of these measures and make recommendations for researchers and clinicians interested in using these assessments.

Cross-cultural validation of expressed emotion in caregivers of Chinese patients with first episode psychosis in Singapore: a qualitative study

BACKGROUND

The concept of Expressed Emotion (EE; Brown et al., 1972), a measure of criticism, over-involvement and hostility in families, has been shown to be a robust predictor of relapse in schizophrenia (Parker & Hadzi-Pavlovic, 1990). Recent criticism of using Western instruments in Asian countries has led to more stringent procedures for validation of scales.

AIMS

The first aim was to establish that the concept of Expressed Emotion exists in Singapore. The second aim was to examine the Level of Expressed Emotion (LEE; Cole & Kazarian, 1988, Gerlsma & Hale, 1997) scale to ascertain the conceptual and construct operationalisation of this instrument in this culture.

METHODS

This was a qualitative study. The concept of EE was examined using a Singaporean population; 10 patient-caregiver pairs were recruited and interviewed using a semi-structured interview format. Regarding the LEE, small focus-group interviews were conducted with a cross-section of Singaporeans to gain their views on the concepts in the scale and the relevance of the items in this culture.

RESULTS

The interviews were analysed in light of attitudes found to discriminate between high and low EE families (Leff & Vaughn, 1985). A clear distinction between high and low EE groups was found. With regard to the LEE, the data from the focus groups, for the most part, supported the cross-cultural conceptual and operational equivalence of the scale and suggestions for additional items were made.

CONCLUSION

There is support for the existence of EE among families in Singapore, and the LEE was found, for the most part, to be applicable in Singapore, with the addition of several emic items.

Expressed emotion in family members of depressed older adults

This study examined similarities between the Expressed Emotion (EE) construct developed in the psychiatric literature and interpersonally relevant constructs derived from gerontology caregiver research. Expressed emotion and other indices derived from the Camberwell Family Interview (CFI) were assessed in 46 adult children and spouses providing care to an older adult hospitalized for major depressive disorder. The relationship of CFI indices with the family member's past and current relationship with the depressed relative, illness attributions, and emotional functioning was examined. Of the family members, 60.9% were classified as high EE. Measures of past and current relationship and illness attributions were significantly associated with most of the CFI indices. In multivariate analyses, past relationship and illness attributions predicted high EE status. Only past relationship predicted the CFI index of warmth. There is conceptual and empirical overlap between the EE construct and interpersonally relevant gerontology variables. Expressed emotion holds promise for a more complex understanding of caregiving and better caregiver interventions.

The Family Questionnaire: development and validation of a new self-report scale for assessing expressed emotion

The level of expressed emotion (EE) as assessed in the Camberwell Family Interview (CFI) has proved to be one of the best predictors of relapse in schizophrenia. The present study describes the development and validation of the Family Questionnaire (FQ), a brief self-report questionnaire measuring the EE status (criticism, emotional overinvolvement) of relatives of patients with schizophrenia. The FQ classifications in the initial sample of relatives (N=76) correlated significantly with the ratings in the CFI subcategories 'criticism' (78% correct classifications) and 'emotional overinvolvement' (71% correct classifications), as well as with the overall CFI EE ratings (74% correct classifications). A validation study in an independent second sample (N=79) yielded similar results. The overall correct classification rate of 74% remained unchanged. The FQ had better agreement with the CFI on emotional overinvolvement than did other short EE questionnaires.

Expressed emotion

Expressed emotion (EE) refers to the quality of the emotional climate between a relative and a family member with a serious psychiatric disorder. Well-established, it has proven to be a reliable predictor of the relapse rate of psychiatric patients. In this article, the Camberwell Family Interview (CFI), the standard instrument, and 11 alternative EE measures will be presented and discussed with regard to their psychometric properties. It is concluded that the CFI remains the best instrument for assessing the quality of the relationship.

Therapeutic interventions focused on the family of bipolar patients

BACKGROUND

Although genetic and biological factors are crucial in the pathophysiology of bipolar disorder, the importance of psychosocial and familial factors in triggering or mitigating relapses warrants the implementation of psychotherapeutic interventions. The authors review and criticize the role of family intervention in bipolar disorder.

METHODS

The main computerized databases (Medline, Psychological Abstracts, Current Contents) have been searched for the terms 'family intervention', 'family management', 'family therapy', 'psychotherapy', 'psychoeducation' and 'bipolar disorder'.

RESULTS

Some studies have associated high expressed emotion in relatives and poorer outcome in bipolar disorder. Studies on families of bipolar patients seem to support that family intervention as adjunctive therapy to pharmacological treatment may reduce the number of relapses and hospitalizations, improving familial, occupational and social functioning. However, controlled studies are scarce and most of them have a great number of methodological pitfalls such as small sample size, uncontrolled pharmacological treatment, absence of long follow-up and biased populations, among others.

CONCLUSIONS

Both bipolar patients and their relatives could benefit from family intervention as adjunctive treatment to pharmacotherapy. Nevertheless, it would be necessary to design further investigations avoiding some of the limitations listed above, and controlling additionally for psychopathology in family members, and the influence of life events. It would be important to distinguish between causes and effects, studying which factors are involved in family attitudes and determining whether the interactive patterns are variable or stable according to the clinical state of the patient. Finally, it would be useful to design viable, effective and measurable interventions for the accurate delimitation of the role of family intervention in the treatment of bipolar disorder.

Perceived expressed emotion in the siblings and parents of hospitalized patients with anorexia nervosa

OBJECTIVE

The present study investigated the relationship between the level of perceived Expressed Emotion (EE) of the siblings and parents of patients hospitalized with anorexia nervosa and its effect on weight gain and psychological functioning.

METHOD

The Level of Expressed Emotion (LEE) Scale was administered on admission to 19 patients with anorexia nervosa who completed the LEE three times so as to identify their perceptions of their relationship with their closest age sibling, mother, and father. They were also required to complete the Eating Disorder Inventory 2 (EDI-2). Patients' closest age sibling completed the Family Attitude Scale (FAS). The patients' body mass index (BMI) was calculated 6 weeks later, and the EDI-2 readministered.

RESULTS

Perceived EE was not predictive of BMI change after 6 weeks of hospitalization. A composite perceived family EE score was a significant predictor of change on the Interpersonal Distrust, Maturity Fears, and Perfectionism subscales of the EDI-2.

DISCUSSION

These findings suggest that patients' perceptions of their relationships with their closest aged sibling, mother, and father are poor predictors of weight gain and improvement in psychological functioning following 6 weeks of inpatient treatment.

Developing family psychoeducational treatments for patients with bipolar and other severe psychiatric disorders. A pathway from basic research to clinical trials

Developing family treatments for patients with severe and persistent psychiatric disorder begins at the basic research level, through identifying psychosocial variables that have prognostic significance. Treatment protocols informed by this basic research can then be designed, manualized, and piloted. Next, the efficacy of a new treatment is examined, first in a randomized trial and then, if successful, in a community effectiveness study. We describe this treatment development pathway in a population for whom family attributes have prognostic importance: patients with bipolar affective disorder. The methodological complexities of psychosocial treatment studies are many. Moreover, the results of these studies often reflect interactions between treatment, process, and outcome variables.

Predictive power and construct validity of the Level of Expressed Emotion (LEE) scale. Depressed out-patients and couples from the general community

BACKGROUND

The Level of Expressed Emotion scale (LEE) is a questionnaire designed to measure the perception of expressed emotion, an important predictor of the course of several psychiatric disorders.

METHOD

In this study, the scale's predictive and construct validity were examined in a sample of 26 clinically depressed out-patients and their partners, and in a sample of 40 couples from the general community.

RESULTS

In the sample of depressed out-patients, the LEE was predictive of depression improvement at six-month follow-up. With regard to the construct validity, results in both samples showed quite strong relationships between the LEE and depressive symptomatology, relational dissatisfaction, and coping styles.

CONCLUSIONS

The LEE may be a useful tool in the study of interpersonal processes and depression, both in clinical and research settings.

The test-retest stability of the five minute speech sample in parents of disadvantaged, minority children

The test-retest stability of the Five Minute Speech Sample, a brief measure of Expressed Emotion (EE), was established in a community sample of predominantly low income, ethnic minority families with children aged from 3 to 14 years. Significant stability was established when Borderline responses were included in the scoring. There was some interchange between High-EE and Borderline-EE, but none of the time one Low-EE respondent gave a second speech sample that included a higher level of EE. Both English and Spanish speaking subjects had stable scores.