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

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.

Positive affect in the family environment protects against relapse in first-episode psychosis

PURPOSE

To evaluate the contribution of positive affect in the family environment to relapse in first episode psychosis.

METHOD

65 service users with a first episode of psychosis were recruited into the current study along with their key relatives. Relatives were interviewed and rated using the Expressed Emotion (EE) measure of warmth, whilst service users completed questionnaires about the positive and negative affects that they perceived from the family environment. Associations between these measures and relapse were examined in a one-year prospective design.

RESULTS

Service users were less likely to relapse within 6 and 12-month follow-up periods when their relatives were rated high on EE warmth, or when they perceived more positive affect from the family. The relationships between service users' perceived positive affect and relapse were preserved after controlling for baseline symptoms, substance use and employment status. Service users' perceptions of positive affect and EE ratings of warmth appeared to be stronger predictors of relapse outcome than criticism and other EE variables.

CONCLUSIONS

Positive family environments may protect against relapse in first episode psychosis. Psychosocial interventions should aim to foster and maintain positive affect in families during the early stages of illness. Further research is needed to understand the mechanisms linking positive affect and outcomes for people recovering from psychosis.

Expressed and Perceived Criticism, Family Warmth, and Symptoms in Schizophrenia

Criticism directed by caregivers towards a family member with schizophrenia, both from the perspective of the patient and of the caregiver, predicts relapse, although both perspectives differ. This study aims to verify if the same applies to a Mediterranean sample, where criticism is not the main attitude of high expressed emotion families. The Camberwell Family Interview was applied to assess the family’s perspective, and the Perceived Criticism and the Family Emotional Involvement and Criticism Scales were used to assess the patients’ perspective, in 21 dyads. The association between both perspectives and psychotic symptoms was also examined. Results replicated those of previous studies in other countries, revealing that the perspectives on Criticism of patients and families do not match. The fact that family members also presented positive attitudes towards the patient did not cushion the patient’s perceived criticism. Thus, it seems that families considered to be critical may not be perceived as such by the patients. Furthermore, only the warmth from the family’s perspective correlated with the symptoms: positive affect proved to be more relevant than negative affect. Therefore, the patients’ subjective assessments and family warmth should be included in clinical and research proposals.

Perceived criticism in schizophrenia: a comparison of instruments for the assessment of the patient's perspective and its relation to relatives' expressed emotion

The expression and perception of expressed emotion (EE) in schizophrenic patients and their relatives are likely to differ. The presented exploratory study compares the two views. EE in relatives of 25 chronic schizophrenic patients was assessed using an extended version of the Five-Minute Speech Sample (FMSS). Patients rated their relatives with the Perceived Criticism Scale (PCS), the Family Emotional Involvement and Criticism Scale (FEICS), and a German questionnaire on family atmosphere (FEF). Forty-eight percent of relatives were rated high in EE, due to criticism in all cases but one. Patients' assessments of the whole family on the FEICS and FEF criticism subscales were related to their relatives' EE status. Correlations between the self-rating instruments were moderate to good. As the patients' and the relatives' views corresponded with regard to the criticism domain, the application of a self-rating instrument may be a simple and useful tool for clinical and research purposes.