The influence of family expressed emotion on the course of schizophrenia in a sample of Spanish patients. A two-year follow-up study

High Expressed Emotion and Warmth among Families of Patients with Schizophrenia in Greece

Expressed emotion (EE) is an established prognostic factor for relapse in schizophrenia. Through critical comments (CC), hostility (H) and emotional overinvolvement (EOI), a relative can be rated as high or low EE, but the role of warmth should also be evaluated in order to consider the influence of a positive affect within the family context. In this study, EE was assessed in a sample of 48 relatives of patients with schizophrenia using the Camberwell Family Interview (CFI). Questionnaires assessing coping (brief-COPE), their wellbeing (World Health Organization Well-Being Index WHO-5) and the socio-demographic variables were also administered. 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). Since the role of warmth is important, it should be taken into account when designing family interventions, independently from lowering EE. Customized interventions to promote warmth and the routine screening of relatives are recommended.

The predictive power of expressed emotion and its components in relapse of schizophrenia: a meta-analysis and meta-regression

BACKGROUND

Schizophrenia is a longstanding condition and most patients experience multiple relapse in the course of the condition. High expressed emotion (HEE) has been found to be a predictor of relapse. This meta-analysis and meta-regression examined the association of global EE and relapse specifically focusing on timing of relapse and EE domains.

METHODS

Random-effects model was used to pool the effect estimates. Multiple random-effects meta-regression was used to compute the moderator analysis. Putative effect moderators including culture, EE measurements, age, length of condition and study quality were included.

RESULTS

Thirty-three prospective cohort studies comprising 2284 patients were included in the descriptive review and 30 studies were included for meta-analysis and meta-regression. Findings revealed that global HEE significantly predicted more on early relapse (⩽12 months) [OR 4.87 (95% CI 3.22-7.36)] than that on late relapse (>12 months) [OR 2.13 (95% CI 1.36-3.35)]. Higher level of critical comments (CC) significantly predicted relapse [OR 2.22 (95% CI 1.16-4.26)], whereas higher level of warmth significantly protected patients from relapse [OR 0.35 (95% CI 0.15-0.85)]. None of the moderators included significantly change the results.

CONCLUSIONS

These findings indicate that there is a dynamic interaction between EE-relapse association with time, and CC and warmth are the two important EE domains to influence relapse among patients with schizophrenia. Results also confirmed the foci of family interventions on reducing CC and improving warmth in relationship.

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.

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.

Family Interventions for Schizophrenia and the Psychoses: A Review

Family psychoeducation as a treatment for schizophrenia was developed 40 years ago almost simultaneously and independently by investigators who at the time were not family therapists. Although the original goal was to decrease high expressed emotion as a means of preventing relapse, later variations have gone beyond to focus on social and role functioning and family well-being. Explicitly disavowing the earlier assumptions that family pathology caused relapse and deterioration, family psychoeducation seeks to engage family members as more sophisticated partners, complementing interventions by clinicians with specialized interactions and coping skills that counter the neurologic deficits inherent to the disorder. It has proved to be one of the most consistently effective treatments available. Reports on outcome studies now number more than 100, while meta-analyses put relapse rate reduction at 50-60% over treatment as usual. The most recent application in first episode and prodromal psychosis, combined with other evidence-based interventions, is yielding perhaps the most promising results yet achieved-substantial return of functioning and avoidance of psychosis altogether. Reviewed here are its scientific, theoretical, and clinical sources, a description of the most commonly applied version-the multifamily group format, selected clinical trials spanning those four decades, international and ethnic adaptations, and studies on mechanisms of efficacy.

Expressed emotion among relatives of chronic pain patients, the interaction between relatives' behaviours and patients' pain experience

BACKGROUND

Chronic pain is a sensory and emotional experience that causes significant disturbances to a patient's life as well as to their family. Whether the family environment is affected by chronic pain and, in turn, affects the patients' pain experience has yet to be investigated. The interaction between patients and spouses has been assessed using the expressed emotion (EE) construct, a tool previously described in the field of mental health. For schizophrenia and other psychiatric illnesses, a correlation exists between family EE and patients' outcomes.

AIMS

The main objective of this study was to observe the presence of EE among relatives of chronic spinal pain patients and to evaluate its correlation with their symptoms.

METHODS

A prospective observational study was conducted on 54 patients and their spouses currently seen at the Chronic Pain Unit of Hospital Clinic of Barcelona. The following variables were recorded: age, gender, pain score, quality of life and EE.

RESULTS

Data showed that a considerable proportion of spouses were rated as high EE. There was an association between EE and patients' quality of life, and the level of EE predicted some other variables of patients' quality of life.

CONCLUSION

The EE level of spouses of chronic pain patients affects the patients' quality of life and thus the way that they experience their pain.

Cultural specificity of emotional overinvolvement: a systematic review

Understanding cross-cultural aspects of emotional overinvolvement (EOI) on psychosis outcomes is important for ensuring cultural appropriateness of family interventions. This systematic review explores whether EOI has similar impact in different cultural groups and whether the same norms can be used to measure EOI across cultures. Thirty-four studies were found that have investigated the impact of EOI on outcomes across cultures or culturally adapted EOI measures. The relationship between high EOI and poor outcome is inconsistent across cultures. Attempts to improve predictive ability by post hoc adjustment of EOI norms have had varied success. Few studies have attempted a priori adaptations or development of culture-specific norms. Methodological differences such as use of different expressed emotions (EE) measures and varying definitions of relapse across studies may explain a lack of EOI outcome relationship across cultures. However, our findings suggest that the construct and measurement of EOI itself are culture-specific. EOI may not necessarily be detrimental in all cultures. The effect of high EOI may be moderated by the unexplored dimension of warmth and high levels of mutual interdependence in kin relationships. Researchers should reevaluate the prevailing concepts of the impact of family relations on the course and outcome of psychotic disorders, specifically focusing on the protective aspects of family involvement. Clinically, family interventions based on EE reduction should take cultural differences into account when treating families from different ethnocultural groups.

Socio-demographic, clinical and treatment characteristics of relapsing schizophrenic patients

AIMS

To define the clinical profile of relapsing patients with schizophrenia attended in daily practice.

METHOD

Patients with schizophrenia/schizoaffective disorder admitted to short-stay/acute-care psychiatric units were eligible provided that data for the previous 3 years and for the next 12 months after discharge were collected.

RESULTS

Remarking features in 1646 patients (68% men) included low family support (34%), primary education (48%), schizophrenia as the main diagnosis (77%), duration of illness > 10 years (60%), mean number of previous hospitalizations of 2.74, non-adherence as the main reason of hospitalization (58.6%), treatment with a mean of two different antipsychotics and differences in adherence according to antipsychotic medication (P < 0.0001) (highest rates for depot atypical antipsychotics). The relapse rate was 38.6%. There were no differences in the number of relapsing patients according to antipsychotic drugs.

DISCUSSION AND CONCLUSION

The profile of relapsing schizophrenic patients may be defined as a male subject, aged 30-45 years, with primary education level, more than 10 years of disease' duration, low family support, moderately and severely ill, treated with multiple antipsychotic drugs, and poor to moderate adherence. Differences in relapse according to antipsychotic types were not observed but long-acting second generation antipsychotic drugs showed the highest percentage of maximum adherence.

Factors associated with relapse in patients with schizophrenia

OBJECTIVE

To assess risk factors for relapse in patients with schizophrenia attended in daily practice.

METHODS

Patients with schizophrenia admitted consecutively to short-stay/acute-care psychiatric units over a 6-month period were eligible. Variables statistically significant in the univariate logistic regression analysis were then subjected to multivariate analysis.

RESULTS

The study population included 1646 patients (67.6% men). In the univariate analysis, low family support, duration of illness > 5 years, number of previous hospitalizations, cocaine and cannabis consumption, and number of different antipsychotic drug classes were risk factors for relapse. In the multivariate analysis, number of previous hospitalizations (odds ratio [OR] 1.29, 95% confidence interval [CI] 1.21-1.36) and number of different antipsychotics previously used (OR = 1.13, 95% CI 1.03-1.24) were significant predictors of relapse. The absence of cannabis consumption was a protective factor (OR = 0.72, 95% CI 0.58-0.89). Neither adherence to treatment in the previous 3 years nor type of antipsychotic regimen was significantly associated with relapse.

CONCLUSIONS

Number of previous hospitalizations and number of different types of antipsychotic drugs were associated with relapse. Absence of cannabis consumption was a protective factor.

Efficacy and effectiveness of individual family intervention on social and clinical functioning and family burden in severe schizophrenia: a 2-year randomized controlled study

BACKGROUND

Empirical evidence of the efficacy and effectiveness of psychosocial family intervention and of the specificity of its effects on the course of schizophrenia is limited. The aim was to study the efficacy and effectiveness of psychosocial family intervention with regard to clinical and social functioning and family burden after controlling for compliance and several prognostic factors.

METHOD

A 2-year randomized controlled trial with blind assessments. Fifty patients with DSM-IV schizophrenia and persistent positive symptoms and/or previous clinical relapse were allocated to psychosocial family intervention, individual counselling and standard treatment versus individual counselling and standard treatment.

RESULTS

Family intervention was associated with fewer clinical relapses, hospitalizations and major incidents, and an improvement in positive and negative symptoms, social role performance, social relations, employment and family burden. The reduction in hospitalizations in the family intervention group was significantly greater than that observed in the group of patients who refused to participate but this was not the case for the control group. The effects of family intervention were independent of compliance and prognostic factors.

CONCLUSIONS

Family intervention is effective in severe schizophrenia independently of compliance and prognostic factors.

Sociodemographic and clinical factors associated with relapse in schizophrenia

The aim of the present study was to examine sociodemographic and clinical factors associated with relapse in schizophrenia. The study group consisted of a convenience sample of 40 schizophrenia patients (20 patients each in relapse and remission). Relapse and remission were defined based on clinical criteria (ICD-10 criteria, course since last episode, and duration of remission) and psychometric criteria (scores on Socio-Occupational Functioning Assessment Scale [SOFAS] and Positive and Negative Syndrome Scale for Schizophrenia [PANSS]). The index group was evaluated after the occurrence of current relapse but within 6 months of its onset. Sociodemographic, current psychopathology (PANSS) and functioning (SOFAS), and other (mainly retrospective) variables were assessed with a specifically designed clinical profile sheet, Schedule for Affective Disorders and Schizophrenia Lifetime version, Presumptive Stressful life Events Scale, and World Health Organization Life Chart Schedule for Assessment of Course and Outcome of Schizophrenia. Patients who had relapsed were more symptomatic and exhibited greater dysfunction in comparison to remitted patients. Relapse in schizophrenia was significantly associated with unemployment, number of psychotic episodes, side-effects of medication, and life events score. The present findings suggest that a severe illness (no. psychotic episodes, unemployment), psychological stress and inappropriate treatment (side-effects of medicines) may be causally related to relapse in schizophrenia. However, the possibility that these variables may be caused by relapse or may be explained by a common underlying variable needs to be assessed prospectively.

Social aspects of ethno-psychopharmacology: an Arab perspective

Some 7000 years ago Egyptians believed in one God, the after-world and that our worldly deeds would be balanced in the day of judgement. This led James Breasted to consider that the emergence of Egyptian culture marked the dawn of conscience (Breasted, 1934; Okasha & Okasha, 2000).

Family interventions for schizophrenia in Italy: randomized controlled trial

OBJECTIVE

To evaluate the effectiveness of multiple group family treatment for Schizophrenia.

METHOD

Relatives were randomly provided with an informative programme (n = 50), or allocated to receive an additional support programme (n = 26). Patients did not attend the programme to overcome cultural and organizational implementation barriers. The 12 and 24 months clinical and family outcomes were assessed.

RESULTS

Patients' compliance with standard care was greater at 12 months in the more intensive behavioural management group over a control group receiving treatment as usual (TAU) (n = 25). A reduction in levels of expressed emotion (EE), significantly more frequent in those receiving the additional support programme than just the informative, occurred after treatment completion. Other clinical and family outcomes did not differ. However, treatment benefits declined at 24 months, when baseline high EE was again predictive of patient's admission and relatives were more vulnerable to objective burden. Baseline illness severity variables predicted a number of medium and long-term poor clinical outcomes.

CONCLUSIONS

Although family psychoeducation has been tested in a wide range of Anglo-Saxon settings, there remains need to assess outcomes more internationally. Effective family interventions for people with schizophrenia probably require continued administration of key-elements or ongoing informal support to deal with the vicissitudes of illnesses.

Expressed emotion and anorexia nervosa: the validation of the Five-Minute Speech Sample in reference to the Camberwell Family Interview

OBJECTIVE

The goal of the current study was to test whether the Five-Minute Speech Sample (FMSS) assessments of expressed emotion (EE) in families with a daughter with anorexia nervosa (AN) are valid in comparison to the Camberwell Family Interview (CFI).

METHOD

The sample included parents of hospitalized patients with AN. Assessments were conducted at the time of patients' discharge from the hospital. The participants (n = 40) were assessed individually with the FMSS and then the CFI. FMSS-EE ratings were classified as high or low for Emotional Overinvolvement (EOI), Critical EE, and Final EE (overall rating). For the CFI, average EE scores were computed on the same subscales.

RESULTS

Comparisons of FMSS subgroups on the CFI mean scores revealed that parents rated high EE on the FMSS subscales (EOI and Final EE) had significantly greater mean scores on the CFI than parents rated low EE on the FMSS (EOI: p = .02; Final EE: p = .04). Furthermore, FMSS-EE ratings were positively correlated to CFI-EE ratings for EOI EE (r = .38, p = .01), Critical EE (r = .31, p = .05), and Final EE (r = .29, p = .07).

CONCLUSION

The FMSS can reliably measure EE in reference to the CFI in terms of Final EE and EOI EE. For the Critical EE subgroup, further investigation is needed with a bigger sample size.

Do all people with schizophrenia receive the same benefit from different family intervention programs?

The study evaluated baseline characteristics that could be used to predict the outcome of family intervention in schizophrenia and focussed on identifying the subgroups of patients who were more likely to respond to one therapeutic modality than another. We conducted a controlled trial in which participants were assigned at random to either a Behavioral Family Intervention Group or a Relatives' Group. Patients in one catchment area, having suffered one psychotic relapse within the previous year and living with their families, were assessed by an independent evaluator at baseline and 12 months later. Some clinical and family factors such as the duration of illness, number of hospital admissions and relatives' level of psychological distress can predict the differential outcome of either type of family intervention modality. The results suggested that the short-term illness group requires more intensive and personal intervention, while the long-term illness group needs more continuous support. Our results should be confirmed in a larger sample before clinical recommendations can be made.

Family psychoeducation and schizophrenia: a review of the literature

Family psychoeducation has emerged as a treatment of choice for schizophrenia, bipolar disorder, major depression, and other disorders. More than 30 randomized clinical trials have demonstrated reduced relapse rates, improved recovery of patients, and improved family well-being among participants. Interventions common to effective family psychoeducation programs have been developed, including empathic engagement, education, ongoing support, clinical resources during periods of crisis, social network enhancement, and problem-solving and communication skills. Application of family psychoeducation in routine settings where patients having these disorders are usually treated has been limited, reflecting attitudinal, knowledge, practical, and systemic implementation obstacles. Through consensus among patient and family advocacy organizations, clinician training, and ongoing technical consultation and supervision, this approach has been implemented in routine clinical settings.

[Social performance expectations in psychiatric patients of a general hospital ward]

OBJECTIVE

To prospectively assess the performance of socially expected activities of psychiatric patients in the first year after their discharge from a psychiatric ward of a general hospital. Also, to evaluate the patients' and their family' expectations on the former's performance.

METHODS

The study was carried out in a general hospital in Ribeirão Preto, Brazil. The Katz Scale was applied to the patient and their family informer at the time of hospitalization regarding to the week preceding admission, and at one, six and 12 months after hospital discharge, regarding to the preceding week. Of the 86 pairs who were initially included in the study, 55 patients (33 women and 22 men) and their respective family informers completed the study. Performance scores and expectations were compared using variance (ANOVA) and t-student test.

RESULTS

Expectation did not show significant variations either in the patient's evaluation or in the family's evaluation. According to both evaluations, expectation was significantly higher than performance. A significant improvement in the performance of socially expected activities was observed as early as one month after discharge compared to the pre-admission period and was unchanged along the first year in both evaluations of the patient and their family.

CONCLUSIONS

These results suggest that admission to a psychiatric ward of a general hospital, in addition to reducing the psychiatric symptoms, contributed to improving the performance of socially expected activities. The average level of performance was unchanged throughout the first year after discharge, although demographic and medical variables can influence these results.

Expressed emotion in relatives of first-episode and chronic patients with schizophrenia and major depressive disorder-a comparison

Relatives of first-episode and chronic schizophrenic and depressed patients were examined with respect to their expressed emotion (EE) status. The two aims of the study were to (1) investigate whether relatives of first-episode patients differed from family members of chronic patients, and (2) whether EE indices of relatives of schizophrenic patients were comparable to those of depressed subjects. Twenty patients of each diagnostic group (DSM-III-R and DSM-IV) were included, i.e. a total of 80 patients. The EE status of key relatives was assessed with the Five-Minute Speech Sample on the basis of critical comments and emotional overinvolvement. Additionally, the new criterion 'covert criticism' was applied to detect indirect expressions of critique. Relatives of first-episode and chronic patients of both diagnostic groups did not differ significantly regarding their EE status; in first-episode patients, 52.5% of relatives were classified high EE; in chronic patients, 45%. Moreover, EE indices of relatives of schizophrenic and depressed patients were comparable. Analysis revealed 52.5 and 45% high-EE relatives in the depression and the schizophrenia subsamples, respectively. Thus, the overall incidence of high-EE relatives was comparable to numbers reported in the literature. In our study EE status of relatives was not disease-specific, and it was independent of chronicity of illness.

Family interventions in schizophrenia: an analysis of non-adherence

OBJECTIVE

The aim of this study was to identify baseline factors which may make it possible to predict non-adherence to prescribed treatment.

METHOD

A total of 87 schizophrenic patients in a catchment area of Valencia (Spain) were randomly assigned to two family strategies. The characteristics associated with lack of adherence to the programmes were analysed in both the patients and their families.

RESULTS

Older patients, those with a higher number of previous hospital admissions, those living in small households and those having relatives with little knowledge of schizophrenia at the time of the initial assessment were the main factors associated with a higher risk of dropping out of the interventions.

CONCLUSIONS

The findings of this study offer some guidance on suggesting intervention strategies that might reduce drop-out rates in these types of programmes.

Social adjustment in schizophrenia: factors predictive of short-term social adjustment in a sample of schizophrenic patients

A sample of 60 Spanish schizophrenic patients was studied in order to ascertain the relationship between their relatives' expressed emotion (EE) and social adjustment after 2 years of follow-up. The average extent of the disability did not increase over time, and differences in dysfunction rates between the various specific social roles were identified. No differences in social outcome were detected between patients with high EE and low EE families. Three factors which predict social adjustment outcome were obtained using logistic regression analysis, namely clinical conditions, baseline social adjustment and the occurrence of a psychotic relapse during the follow-up period.

Expressed emotion among families and course of schizophrenia in Japan: a 2-year cohort study

A 2-year cohort study was conducted to determine whether expressed emotion (EE) in families is associated with relapse of schizophrenia in Japan. Key relatives of 52 schizophrenic patients were interviewed using the Camberwell Family Interview (CFI) and the patients were classified into high and low EE groups. The 2-year relapse risks were 71% (17/24) in the high EE group and 37% (10/27) in the low EE group. The risk ratio was 1.9 and the 95% confidence interval (CI) ranged from 1.1 to 3.3. In the multiple logistic regression analysis, the odds ratio between families' EE and schizophrenic relapse was 4.6, controlling for other potential confounding factors. It was concluded that, in Japan, the families' EE is a good predictor for schizophrenic relapse within 2 years. This association between EE and relapse could be due to the strong difference in the first 9 months. The period during which EE's predictive validity for schizophrenic relapse is applicable may vary according to the society to which the patients and their families belong.

Family environment predictors of outcome in schizophrenic patients in Spain: a nine-month follow-up study

This study investigates the effects of perceived family environment on clinical outcome among patients in Spain who suffer from schizophrenia. Forty-five consecutively admitted DSM-III-R schizophrenic patients were assessed monthly with the Brief Psychiatric Rating Scale during a 9-month period. Patients and parents rated the family environment through the Family Environment Scale (FES). FES factors were considered separately for each family member, since parents' and patient's perceptions of the family environment were weakly correlated. Stepwise multiple regression analysis showed that patients' perceptions of family control and intellectual-cultural orientation predicted rehospitalization. Patients' and mothers' ratings of family control and fathers' scores of conflict and moral religious emphasis predicted psychotic relapse. However, fathers' scores of family cohesion predicted higher negative symptoms. Prior admissions, age of onset and use of depot medication tended to predict outcome in conjunction with the family variables.

Relationship between family attitudes measured by the Semantic Differential and relapse in schizophrenia: a 2 year follow-up prospective study

A prospective study was carried out to investigate the relationship between family attitudes and relapse in a cohort of 80 schizophrenic patients followed up for 2 years. A significant relationship was found between attitudes as measured by means of a semantic differential during hospitalization and later relapse. Lack of treatment compliance, negative symptoms, unemployment and poor pre-morbid adjustment were also associated with relapse. In a multivariate analysis some of these variables changed their predictive power but the association between attitudes and relapse was maintained.

The clinical utility of expressed emotion in schizophrenia

The measure expressed emotion (EE) has been developed over the course of the last 35 years, but it is only over the last decade that there has been an explosion of interest in it. It taps attitudes and behaviour in those who care for people with a range of psychiatric and physical conditions. It has been the basis for successful studies of psychosocial intervention in schizophrenia. However, several questions remain to be answered concerning EE. This article summarizes the results of an aggregate analysis of 25 studies of EE, which appears to be a robust predictor of relapse, in a range of locations and cultures, and in both sexes. Medication and family atmosphere exert effects on relapse that are completely independent. High contact with high-EE relatives increases relapse rates still further, while if anything contact with low-EE relatives is protective. We describe what is known about the relationship of EE with the behaviour of patients and carers. It is now clear that staff members can exhibit the same range of behaviours as the relatives of sufferers. Finally, we set out the implications for the routine management of people with longstanding schizophrenia.

The predictive utility of expressed emotion in schizophrenia: an aggregate analysis

We analysed aggregate data from 25 studies linking Expressed Emotion (EE) and schizophrenia. We had access to original data sets from 17 studies, and used published data from the remainder. This provided us with 1346 cases from around the world. The association of EE with relapse was overwhelming, and was maintained whatever the geographical location. The predictive capacity of EE was virtually identical in men and women. While high contact with a high EE relative increased the risk of relapse, the opposite was true in low EE households. Medication and EE were independently related to relapse, and thus EE status has no bearing on the decision to prescribe. Our findings were confirmed using log-linear analysis.

Symptoms and social adjustment of schizophrenic patients as evaluated by family members

The purpose of this study is to reveal the relationship between family expressed emotion (EE) and family evaluation for symptoms and social adjustment of schizophrenic patients. Chronic schizophrenic outpatients in offshore islands under stationary therapeutic conditions were studied. For evaluation, the Five Minute Speech Sample (FMSS) for EE and the Katz Adjustment Scale (KAS) for family evaluation of patients were used. EE level was high among relatives who thought the patient was belligerent, negativistic, unstable or helpless. High-EE relatives tended to evaluate their patients' performance of social activities rather low and showed strong dissatisfaction with the patient's leisure activities. Moreover, a high emotional overinvolvement (EOI) value is more common in Japan than in other countries. A subgroup of the FMSS-EOI, the emotional display, was seen where many mothers began to cry while speaking.