Expressed emotion, social skill, and response to negative affect in schizophrenia

Caregiving processes and expressed emotion in psychosis, a cross-cultural, meta-analytic review

The construct of Expressed Emotion (EE) is a reliable predictor of relapse in psychotic disorders globally. However, cultural differences in the level and manifestation of EE have been reported. This review was conducted in line with PRISMA guidelines to demonstrate the distribution of EE and its domains cross-culturally as well as its relationship with relapse in psychosis. Ninety-six studies reported global EE scores and/or separate EE domains amongst caregivers of a family member with psychosis and used the Camberwell Family Interview (CFI) to measure EE. In the meta-analysis (k = 34, n = 1982), exposure to high EE was indicative of a 95% increased likelihood of relapse compared to low EE. However, no significant effect of geographical region on global EE scores (high/low) or EE domains was found. Several adjustments to the scoring of the CFI were highlighted based on cultural norms, particularly relevant to the domains of emotional over-involvement, warmth and criticism. Although this made meaningful quantitative comparisons across studies difficult, it nonetheless highlighted cultural considerations that need to be taken into account when interpreting EE and understanding its relationship to clinical outcomes. There is not a universal normative EE experience, with cultural variation in the scoring and interpretation of EE existing as evidenced by adjusted cut off scores and conceptualisation of EE constructs. Thus, it is important for clinical practitioners to have an awareness of different cultural norms in relation to caregiving and care receiving behaviours, which can inform adaptations to clinical interventions in multicultural settings.

Are family warmth and positive remarks related to outcomes in psychosis? A systematic review

BACKGROUND

Affective attitudes and behaviours manifested within the family environment have been characterised as expressed emotion (EE). High EE environments have been robustly shown to put psychosis patients at a greater risk of relapse compared with low EE exposure. Positive EE dimensions (warmth; positive remarks) have received far less attention than negative EE dimensions such that EE has become synonymous with a negative family atmosphere; the predictive value of positive EE dimensions is largely ignored. A systematic review examining the relationship between positive family EE and outcomes in psychosis is needed.

METHODS

A systematic search was conducted. Studies reporting bias and study quality were assessed.

RESULTS

A total of 2368 studies were identified. Of these, 27 met eligibility criteria reporting outcomes including relapse, symptomatology, social functioning and life satisfaction. Relapse was the most commonly measured outcome. Stronger evidence emerged for the association between EE warmth and outcomes compared with EE positive remarks, with effects mostly evident in the early phase of psychosis. Evidence for protective effects of warmth on relapse was found up to 9 months follow-up. No effects were evident between positive remarks and relapse. Studies assessing symptom outcomes showed inconsistent findings. Evidence for an association with social functioning was evident, primarily in at risk mental states. Warmth and positive remarks predicted life satisfaction.

CONCLUSIONS

The positive aspects of EE require further investigation with longitudinal research designs. Clinical interventions should focus not only on reducing negative aspects of EE but also foster warmth within families in the context of psychosis.

Perceived expressed emotions in relatives of patients with severe mental illness: A comparative study

There is paucity of studies on expressed emotion (EE) in families of patients with severe mental illness in sub-Saharan Africa. This study aimed to assess and compare the levels of expressed emotion (LEE) in relatives of patients with schizophrenia and bipolar affective disorder attending an out-patient clinic in Southwestern Nigeria. One hundred and forty consecutive clinic attendees with Mini-Plus diagnosis of schizophrenia and bipolar affective disorder and 140 accompanying relatives were recruited. The patients and relatives were interviewed using a socio-demographic questionnaire. The perceived level of expressed emotion was assessed using the client version of the Level of Expressed Emotion Questionnaire (LEEQ). Although, the prevalence of high expressed emotion was higher among relatives of patients with schizophrenia when compared with relatives of patients with bipolar affective disorder (41% vs 37%), the difference was not statistically significant. The socio-demographic characteristics of the relatives of patients with these disorders were not significantly related to high EE. High expressed emotion is just as prevalent among relatives of patients with bipolar affective disorder as among relatives of patients with schizophrenia and clinicians should give similar attention to early detection of high EE and intervention in this population of patients and their relatives.

An Interpersonal CBT Framework for Involving Relatives in Interventions for Psychosis: Evidence Base and Clinical Implications

Working with families in psychosis improves outcomes and is cost effective. However, implementation is poor, partly due to lack of a clear theoretical framework. This paper presents an interpersonal framework for extending the more familiar cognitive behavioral therapy model of psychosis to include the role of relatives' behavior in the process of recovery. A summary of the framework is presented, and the evidence to support each link is reviewed in detail. Limitations of the framework are discussed and further research opportunities highlighted. Clinical implications and a case example are described to show how the framework can be used flexibly to facilitate clinical practice. Our aim is to shift the focus of psychosocial interventions from an individualistic approach to treatment, towards greater involvement of relatives and recognition of the importance of the social environment on mental health.

The Meaning of Emotional Overinvolvement in Early Development: Prospective Relations With Child Behavior Problems

Emotional overinvolvement (EOI) in parents’ Five Minute Speech Samples (FMSSs; Magaña-Amato, 1993) is thought to measure overconcern and enmeshment with one’s child. Although related to maladaptive outcomes in studies of adult children, FMSS EOI evidences varied relations with behavior problems in studies with young children. These mixed findings may indicate that certain FMSS EOI criteria reflect inappropriate and excessive involvement with adult children, but do not indicate maladaptive processes when parenting younger children. Thus, this study evaluated relations of each FMSS EOI criterion with changes in child behavior problems from preschool to first grade in a community sample of 223 child–mother dyads (47.98% female; Wave 1 M(age) 49.08 months; 56.50% Hispanic/Latina). Maternal FMSS EOI ratings were obtained at Wave 1, and independent examiners rated child externalizing and internalizing behavior problems at Wave 1 and again 2 years later. Path analyses indicated that both the self-sacrifice/overprotection (SSOP) and statements of attitude (SOAs) FMSS EOI criteria predicted increased externalizing problems. In contrast, excessive detail and exaggerated praise were not related to child externalizing behavior problems, and Emotional Display was not evident in this sample. None of the FMSS EOI criteria evidenced significant relations with internalizing behavior problems. Multigroup comparisons indicated that the effect of SOAs on externalizing behavior problems was significant for boys but not for girls, and there were no significant group differences by race/ethnicity. These findings point to the salience of SSOP and SOAs for understanding the developmental significance of EOI in early development.

A brief cognitive-behavioural social skills training for stabilised outpatients with schizophrenia: a preliminary study

Achieving social functioning and achieving social competence are two main objectives of psychosocial interventions for people suffering from schizophrenia. The present preliminary study presents a novel approach of social skills training (SST) based on the proposals of Kopelowicz et al. (Kopelowicz, A., Liberman, R. P., and Zarate, R., 2006. Schizophr. Bull. 32 (1): S12-23) that link the treatment to seven specific target behaviours: social perception, social information processing, responding and sending skills, affiliative skills, interactional skills, and behaviour governed by social norms. Thirty-one stabilised outpatients were randomly assigned to one of two groups, SST (n=13) or treatment-as-usual (n=18) (TAU; case management, medication adherence, psychotherapy, leisure engagement, and family support) and were assessed at baseline in cognitive performance, clinical symptomatology, social cognition, and psychosocial functioning. These outcomes were evaluated across post-treatment and at the 6-month follow-up appointment. SST subjects showed improvements in psychopathology, social discomfort, social cognition (self-regulation statements during interactions), social withdrawal, interpersonal communication, and quality of life compared with the TAU group. At the 6-month follow-up, results were maintained for negative symptoms, social discomfort, and some functioning outcomes. Neuropsychological variables were also examined, as mediators of benefit from skills training. Results support the efficacy of the brief SST for outpatients with schizophrenia and show the need to implement empirically supported interventions in mental health services to enhance patients' social functioning and quality of life.

The relationship between neurocognition and social cognition with functional outcomes in schizophrenia: a meta-analysis

The current systematic review and meta-analysis provides an extended and comprehensive overview of the associations between neurocognitive and social cognitive functioning and different types of functional outcome. Literature searches were conducted in MEDLINE and PsycINFO and reference lists from identified articles to retrieve relevant studies on cross-sectional associations between neurocognition, social cognition and functional outcome in individuals with non-affective psychosis. Of 285 studies identified, 52 studies comprising 2692 subjects met all inclusion criteria. Pearson correlations between cognition and outcome, demographic data, sample sizes and potential moderator variables were extracted. Forty-eight independent meta-analyses, on associations between 12 a priori identified neurocognitive and social cognitive domains and 4 domains of functional outcome yielded a number of 25 significant mean correlations. Overall, social cognition was more strongly associated with community functioning than neurocognition, with the strongest associations being between theory of mind and functional outcomes. However, as three-quarters of variance in outcome were left unexplained, cognitive remediation approaches need to be combined with therapies targeting other factors impacting on outcome.

Neurocognition and social skill in older persons with schizophrenia and major mood disorders: An analysis of gender and diagnosis effects

Effective social interactions necessary for getting affiliative and instrumental needs met require the smooth integration of social skills, including verbal, non-verbal, and paralinguistic behaviors. Schizophrenia is characterized by prominent impairments in social and role functioning, and research on younger individuals with the illness has shown that social skills deficits are both common and distinguish the disease from other psychiatric disorders. However, less research has focused on diagnostic differences and correlates of social skills in older persons with schizophrenia. To address this question, we examined diagnostic and gender differences in social skills in a community-dwelling sample of 183 people older than age 50 with severe mental illness, and the relationships between social skills and neurocognitive functioning, symptoms, and social contact.Individuals with schizophrenia had worse social skills than those with bipolar disorder or major depression, with people with schizoaffective disorder in between. Social contact and cognitive functioning, especially executive functions and verbal fluency, were strongly predictive of social skills in people with schizophrenia and schizoaffective disorder, but not those with mood disorder. Other than blunted affect, symptoms were not predictive of social skills in either the schizophrenia spectrum or the mood disorder group. Older age was associated with worse social skills in both groups, whereas female gender was related to better skills in the mood disorder group, but not the schizophrenia group. The findings suggest that poor social skills, which are related to the cognitive impairment associated with the illness, are a fundamental feature of schizophrenia that persists from the onset of the illness into older age.

Bridging the gap: using microsociological theory to understand how expressed emotion predicts clinical outcomes

Research has shown that expressed emotion (EE) among families is a strong predictor of relapse for people with severe mental illness. Recent studies have also found the presence of EE in consumer-provider relationships. Despite high consistency in the findings related to EE and relapse, the concept has weak validity as little is known about how exactly it triggers relapse. Microsociological theory provides a framework with which to analyze social interaction and, more specifically, understand how interactions relate to the emotions of pride and shame. By identifying the components of interaction rituals, the theory provides insight into the key processes underlying EE and demonstrates how methodologies based on direct observation have the potential to measure EE with greater validity. This article describes how microsociological theory can be applied to the concept of EE.

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.

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.

Expressed emotion and social functioning in chronic schizophrenia

The aim of this study was to reveal the relationships between family expressed emotion (EE), family evaluations of social functioning, and the psychopathologic symptoms of patients with schizophrenia. We examined whether EE influenced the social functioning of patients with schizophrenia. Forty-four subjects with schizophrenia and 82 of their relatives participated in this study. The Five-Minute Speech Sample (FMSS) was conducted to evaluate EE, and subjects were divided into high-EE and low-EE groups. The Positive and Negative Symptom Scale (PANSS) was used to assess symptom severity. Social functioning was compared between the two groups using the Social Functioning Scale (SFS). No differences in symptom severity or social adjustment, as evaluated by a global assessment of functioning, were observed between the two groups. However, the high-EE relatives tended to evaluate the social functioning of the schizophrenia patient in their family as being rather low and showed a strong dissatisfaction with the patient's social withdrawal and level of independence (competence). Furthermore, low-EE relatives in high-EE families showed the same tendencies. The family members who were evaluated as low-EE relatives in a high-EE family were dissatisfied with the patient's social withdrawal, level of independence (competence), and also their interpersonal functioning. In the chronic stable phase of schizophrenia, the attention of the family members may be more directed towards changes in social functioning; thus, the EE may reflect a family's attitude towards improvements in the patient's social functioning.

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.

Parent-child interactions in relation to critical and emotionally overinvolved expressed emotion (EE): is EE a proxy for behavior?

Expressed emotion measures, encompassing dimensions of criticism (CRIT), and emotional overinvolvement (EOI) are increasingly being used to assess the parent-child relationship in child clinical populations, despite the lack of studies assessing their validity. We examined the correspondence between CRIT, EOI, and parent-child interactions as observed by neutral coders in a sample of 252 clinic-referred children and adolescents, ages 7-17 years. We found support for the validity of the CRIT code, with high critical parents showing more antagonism, negativity, disgust, harshness, and less responsiveness, compared to parents who scored in the low or borderline ranges. In contrast, none of the observed behaviors were found to correspond with parental EOI, suggesting either that this construct lacks validity with juvenile samples or that behaviors that correspond to EOI are difficult to observe. We conclude that high parental CRIT can be used as an index of problematic parent-child interactions.

Race, Family Interactions, and Patient Stabilization in Schizophrenia

This study examined family interactions associated with a failure to stabilize in schizophrenia. Fifty-eight patient and parent dyads completed a problem-solving task soon after an acute episode. Stabilization was assessed over the following 6 months. African American patients' self-initiated discussions of substance use and increased anxiety during the interaction were associated with a failure to stabilize. Nonstabilization in White patients was associated with high levels of both the patients' odd thinking and the parents' criticism. White patients who were depressed during the interaction were also less likely to stabilize. Findings suggest that family relationships may play in important role in determining whether patients stabilize after an acute episode. Results also point to the importance of cultural factors in predicting patient stabilization.

Emotional responses to psychosocial stress in schizophrenia: the role of individual differences in affective traits and coping

Despite the well-established association between psychosocial stress and symptom exacerbation in schizophrenia, factors that account for variability in stress reactivity among individuals with this disorder are unknown. This study examined the association between affective traits, coping style, and neurocognitive functioning and subjective emotional responses during putatively stressful social interactions among individuals with schizophrenia. Self-reported mood was assessed in male schizophrenia outpatients (n=36) and matched nonpsychiatric controls (n=15) during a role-play test (RPT) comprised of simulated social encounters requiring assertive or affiliative skills. During the RPT, schizophrenia patients and controls reported similar elevations in negative mood and decreases in positive mood as compared to baseline mood during assertion scenes. Affiliation scenes resulted only in similar decreases in positive mood across groups as compared to baseline mood. Among schizophrenia patients, trait negative affectivity (NA) and maladaptive coping style accounted for one quarter of the variance in negative mood during the assertion RPTs, and these relationships held after controlling for baseline mood, clinical symptoms, and neurocognitive functioning. Results provide preliminary support for the validity of the social RPT as a paradigm for examining psychosocial stress in schizophrenia and suggest that trait negative affectivity and maladaptive coping are associated with individual differences in emotional responses to psychosocial stressors in schizophrenia.

Emotion recognition via facial expression and affective prosody in schizophrenia: a methodological review

Disturbances in affect recognition may be one of the most pervasive and serious aspects of the schizophrenic patient's interpersonal problems. Interest in the decoding of emotional information in schizophrenia has focused on facial affect recognition with 29 experimental papers on that topic published since 1987. A smaller literature exists on the topic of recognition of affect in speech and there are at least seven studies, which have examined both face and voice perception in the same individuals with schizophrenia. This paper includes a comprehensive analysis of the schizophrenia facial affect recognition research over the past decade and the schizophrenia literature on affective prosody, and provides the first review of the schizophrenia literature on multichannel emotion recognition research. The weight of evidence would suggest that individuals with schizophrenia experience problems in the perception of emotional material; however, the specificity, extent, and nature of the deficits are unclear. Emotion recognition research in schizophrenia should be informed by the general literature on emotion recognition with serious attention paid to methodological issues.

Predicting expressed emotion: a study with families of obsessive-compulsive and agoraphobic outpatients

The authors used structural equation modeling to examine expressed emotion (EE) in relatives of outpatients with panic disorder with agoraphobia (n = 42) or obsessive-compulsive disorder (n = 60). EE was examined as a function of patients' illness and personality and as a function of characteristics of relatives themselves. EE was operationalized in terms of hostility on the Camberwell Family Interview (C. E. Vaughn & J. P. Leff, 1976) and patients' ratings of their relatives' criticism (perceived criticism). Key findings include the identification of a characteristic of the relative (self-reported angry thoughts, feelings, and behaviors) that is directly linked to both hostility toward the patient and to perceived criticism, as well as a direct path between relatives' low rates of observed problem solving and their hostility toward the patient. Patient Pathology predicted perceived criticism but not observer-rated hostility.

Effects of behavioural family management on family communication and patient outcomes in schizophrenia

BACKGROUND

Family interventions for schizophrenia have proved to be highly effective in preventing relapse, but it is not clear how they work or how they should be structured.

AIMS

To examine the effects of a behavioural family intervention and a family support programme on communication, problem solving and outcome in order to determine the impact of structured communication training.

METHOD

Patients and family members participating in the Treatment Strategies in Schizophrenia study were videotaped engaging in 10-minute problem-solving conversations at baseline and after the conclusion of the family intervention. Tapes were subsequently evaluated for changes in communication patterns.

RESULTS

The intensive behavioural intervention did not produce differential improvement in communication, and change in communication was unrelated to patient outcomes.

CONCLUSIONS

The data suggest that intensive behavioural family interventions may not be cost efficient, and that change in family communication patterns may only be important for a subset of families.

Examining an affect regulation model of substance abuse in schizophrenia. The role of traits and coping

Comorbid substance use disorders occur frequently in schizophrenia with significant detrimental effects to clinical outcome. Unfortunately, attempts to identify factors associated with comorbid substance use disorders (beyond demographic characteristics such as gender) have not been successful. This study examined an affect regulation model of comorbid substance use in schizophrenia with a focus on personality traits and coping. It was hypothesized that maladaptive coping and the traits of negative affect (NA) and disinhibition (DIS), but not trait positive affect (PA), would be associated with greater substance use problems. Thirty-nine patients with schizophrenia or schizoaffective disorder completed measures of personality traits, coping, and negative consequences associated with substance use. Traits were differentially associated with coping in that NA and DIS, but not PA, were associated with maladaptive coping including the use of drugs and alcohol to cope with stress. Alternatively, PA, but not DIS or NA, was related to adaptive coping strategies. Individuals high in NA and endorsing the use of drugs and alcohol to cope reported the greatest number of negative consequences from substance use. This finding held after controlling for gender. These results are consistent with an affect regulation model of substance use and suggest the advantage of examining the role of affect, traits, and coping in understanding comorbid substance use in schizophrenia.

Risperidone versus haloperidol for perception of emotion in treatment-resistant schizophrenia: preliminary findings

Currently, little is known about the pharmacological effects of the new generation of antipsychotic medications on perception of emotion in schizophrenia. The present study was designed to compare the effects of risperidone versus haloperidol on the ability to perceive emotion in 20 treatment-resistant schizophrenia patients, using a double-blind design. Measures of emotion perception included a facial emotion identification test (still photographs presented on videotape), a voice emotion identification test (audiotape), and an affect perception test (brief interpersonal vignettes presented on videotape). These measures were administered during the final week of baseline and after 8 weeks of double-blind medication. Risperidone treatment produced a greater effect on patients' ability to perceive emotion compared with haloperidol treatment. Additionally, all patients who received risperidone demonstrated improvement in performance between baseline and retest, compared with four of the nine patients who received haloperidol. When changes in positive symptoms were statistically controlled, the results remained significant. These findings suggest that resperidone may facilitate patients' ability to accurately perceive emotion, an effect which may be mediated either directly by risperidone's pharmacological action or perhaps indirectly by its influence on basic neurocognition.

Evaluation of problem solving and communication skills of persons with schizophrenia

Although much research has shown positive outcomes of teaching problem solving and communication skills to persons with schizophrenia, the amount of research on the assessment of these two sets of skills has been modest. The current study demonstrates an effective model for their assessment and includes a previously neglected procedure to determine if subjects attended to the skill prompts. It replicates and expands prior findings on problem solving and communication skills. Results indicated that persons with schizophrenia were generally deficit in problem solving skills. Persons without schizophrenia seemed to use more behavioral information when deciding if a problem existed and they were better able to differentiate between appropriate and inappropriate solutions to problems. Persons with schizophrenia were found to be deficit in communication skills that facilitate interaction and showed a style that subordinated their wants to those of others.

Factors that affect social cue recognition in schizophrenia

Earlier research (Corrigan and Green, Am. J. Psychiatry, 150 (1993) 589-594) showed fairly symptomatic persons with schizophrenia give more false-positive responses when answering questions about abstract cues in a social situation (i.e. affect, rules, and goals inferred about an interpersonal situation) than concrete cues (i.e. actions and dialogue observed in a situation). It is unclear, however, whether differential cue recognition is due to schizophrenia per se, or some aspect of the illness commensurate with significant symptoms and in-patient care. Moreover, the abstract and concrete dimension in the earlier study had not been independently validated. In this study, the 288 items of the Social Cue Recognition Test (SCRT) were divided into three sets based on abstraction ratings provided by 38 college students. The SCRT was then completed by 48 participants with DSM-III-R diagnoses of schizophrenia or schizoaffective disorder. Participants with schizophrenia were divided into low and high symptom groups using scores from the Brief Psychiatric Rating Scale. Results showed both low symptom and high symptom groups exhibited a differential deficit in cue recognition. False positives were greater for items rated as more abstract. Implications for understanding the social cognitive deficits of persons with schizophrenia are discussed.

Relatives' emotional warmth towards patients with schizophrenia or related psychoses: demographic and clinical predictors

Despite the importance of relatives' emotional warmth for outcome in schizophrenia, no studies to date have addressed demographic and clinical predictors of warmth. We examined a Norwegian sample of 47 recently hospitalized patients (with schizophrenia or schizophreniform disorder) and 72 key relatives. Relatives' emotional warmth was assessed by means of the Camberwell Family Interview. Regression analyses showed that no substance abuse (especially amphetamines), better premorbid adjustment (12-15 years), a chronic social security status, and the relative not being a parent were the strongest predictors of emotional warmth. Emotional warmth was not related to patients' symptoms.

Criticism and hostility in relatives of patients with schizophrenia or related psychoses: demographic and clinical predictors

Relatives' criticism and hostility are important risk factors for relapse in schizophrenia. In order to explain these attitudes, we examined a Norwegian sample of 47 recently hospitalized patients (with schizophrenia or related psychoses) and 72 relatives. Relatives' expressed emotion was assessed by means of the Camberwell Family Interview. Demographic and clinical data were used as predictor variables in confirmatory regression analyses. The most robust predictors of high levels of criticism were, on the part of the patient, lack of paid employment, more than 3 previous hospital admissions, more troublesome behaviours reported by relatives, especially anxiety/depression, and better cognitive functioning at admission. Robust predictors of hostility were lack of employment and more than 3 previous hospitalizations. Interventions to reduce criticism should include employing patients and working with relatives' unrealistic expectations.

Affect recognition in schizophrenia: a function of global impairment or a specific cognitive deficit

To investigate cognitive variables related to affect recognition in schizophrenia, 63 subjects with DSM-III-R diagnoses of schizophrenia or schizoaffective disorder were administered a test battery which included the Bell-Lysaker Emotion Recognition Task (BLERT), Wisconsin Card Sorting Test (WCST), Wechsler Memory (WMS-R) and Adult Intelligence Scales (WAIS-R), Hopkins Verbal Learning Test, Gorham's Proverbs, and Continuous Performance Task (CPT). Coefficients revealed a moderate relationship between emotion recognition and WCST and CPT but no significant relationship with other test variables. Multiple regression analysis demonstrated that approximately one-third of the variance in BLERT scores could be explained by cognitive variables including the Digit Symbol Subtest, CPT, and Hopkins Verbal Learning Test. Other analyses demonstrated that subjects with moderate to severe affect recognition impairment had more perseverative errors, had fewer complete categories on the WCST and had more errors on the CPT. However, there were no significant differences on global measures of impairment such as WAIS-R IQs and Digit Symbol Substitution Test. The discussion focuses on deficits in affect recognition as a distinct feature which contributes to the heterogeneity of the disorder.

Post-hospitalization treatment adherence of schizophrenic patients: gender differences in skill acquisition

A cohort of acutely ill, hospitalized patients with chronic psychotic disorders participated in a study of a manualized community reintegration skills training program. Initial data analyses revealed that skill levels improved significantly over the course of treatment, and that higher post-training skill levels were associated with better post-discharge functioning for the group as a whole. Post-discharge treatment adherence rates were dramatically better in females, and analyses were conducted to determine the role of gender. Males and females had different predictors of post-training skill level and post-discharge treatment adherence. In males, who as a group were at higher risk for poor post-discharge outcome, there was a positive association between post-training skill level and post-discharge treatment adherence. Females, on the other hand, showed good post-discharge treatment adherence regardless of post-training skill or symptom levels. This report is consistent with prior studies suggesting that male and female individuals with schizophrenia show differential patterns of social skill, skill improvement, and social adjustment.

Emotional overinvolvement in parents of patients with schizophrenia or related psychosis: demographic and clinical predictors

BACKGROUND

Parental emotional overinvolvement (EOI) may entail a worse outcome in schizophrenia. In the present study we examined demographic and clinical predictors of EOI.

METHOD

The predictors were examined in a Norwegian sample of 41 recently admitted patients (schizophrenia or schizophreniform disorder) and 66 parents. Parents' expressed emotion was assessed by the Camberwell Family Interview.

RESULTS

Regression analyses showed that higher EOI was significantly related, on the part of the parent, to being a mother, single, spending more time with the patient; and, on the part of the patient, to no substance misuse, more anxiety-depression, and less uncritical and aggressive behaviour. EOI was not linked to previous hospital admissions.

CONCLUSION

Our analyses indicate that characteristics of the parent and of the parent-patient dyad seem to be the most important determinants of EOI. EOI is probably not linked to psychotic relapse, but rather to affective disturbances in the patient.

Situational feature recognition in schizophrenic outpatients

Previous research has suggested that patients with schizophrenia are significantly better at identifying relatively concrete features that describe social situations (e.g., actions and roles) than more abstract features (e.g., rules and goals). Because participants in the earlier research were all inpatients, the results may have been confounded by various factors that are commensurate with a hospital stay. Thirty-one patients with DSM-III-R diagnoses of schizophrenia or schizoaffective disorder and 39 normal volunteers completed the Situational Feature Recognition Test to determine whether they also showed the differential deficit. Results showed that the outpatient group was, indeed, less symptomatic than the inpatient group; outpatients also showed better overall feature recognition than inpatients. Schizophrenic outpatients and normal volunteers are significantly better at identifying concrete features than abstract features. Additional analyses suggested that the differential deficit in outpatients is due, in part, to their disorder. Implications for the remediation of social functioning deficits are discussed.

Effects of extraneous stimuli on social cue perception in schizophrenia

Competing hypotheses that explain the effects of emotionally arousing, extraneous auditory stimuli on the social cue perception of schizophrenic patients were examined in this study: (1) extraneous arousing stimuli enhance patients' cue perception; (2) extraneous stimuli distract patients, and cue perception is diminished. Twenty-five patients with DSM-III-R diagnoses of schizophrenia completed a cue-perception task in which half of the videotaped vignettes included in the task were presented with simultaneous extraneous stimuli and half were not. Item difficulty and consistency across extraneous stimuli conditions were matched on standardization and cross-validation samples. Results showed that schizophrenic subjects were significantly more sensitive to cues when exposed to extraneous stimuli, thereby supporting the first hypothesis. This effect was also observed in a subgroup of schizophrenic subjects who demonstrated a distraction decrement on another test of short-term recall. The presence of extraneous stimuli interacted with perception of abstract cues; that is, schizophrenic subjects were particularly better at perceiving abstract cues when extraneous stimuli were presented simultaneously. Future research needs to determine characteristics of extraneous stimuli that enhance cue perception.

Family interactions of schizophrenic and schizoaffective patients: determinants of relatives' negativity

Videotaped family problem-solving interactions of 57 schizophrenic or schizoaffective patients and their relatives were examined for predictors of negativity of their communication behavior. Ratings of patients' behaviors and independent assessments of patients' symptomatology were used to predict the negativity of relatives in the videotaped interaction. The results indicated that severity of symptomatology was not related to relatives' negativity. Patients' social skill, as independently assessed by a role-play test, also was not associated with relatives' negativity. The regression results suggest that with both members of a patient-relative dyad, the quality of communication in a discussion is related to the other participant's level of negativity.

Behavioral family management for serious psychiatric illness

A description of the various elements that characterize a behavioral family management approach is presented in this chapter. The goal is to teach techniques to families for reducing the stress that their vulnerable relative might face.