Prediction of schizophrenic relapse using the parental bonding instrument

Evaluation of parent bonding style and traumatic experiences in patients with schizophrenia and bipolar disorder: A case-control study

BACKGROUND

There is no consensus about the etiology of schizophrenia (SQZ) and bipolar disorder (BD). Both hereditary and environmental factors are recognized, but the importance of variables like the role of parental attachment and trauma is still under research.

AIMS

Evaluate and compare the patient-parent bonding and the frequency and severity of various types of trauma in patients with SQZ, BD, and a control group from Primary Health Care.

METHOD

This study included 50 patients with SQZ and 50 with BD followed at a psychiatric hospital, through a convenience sample. Each participant of the clinical sample was paired with a control with no psychiatric background of the same gender and similar age, from a primary health center. Two scales were applied - Parental Bonding Instrument (PBI) and Childhood Trauma Questionnaire - Short Form (CTQ-SF).

RESULTS

Regarding PBI, there was a higher frequency of the most dysfunctional attachment style (affectionless control), in patients with SQZ and BD, with p < .001 (always), both for the father and the mother. In addition, ideal parenting style (optimal parenting) was significantly more common in control samples, with p = .002 or <.001, both for the father and for the mother. Trauma was more frequent and severe in SQZ and BD than controls, in all evaluated dimensions. Again, differences between groups are obvious, with p = .012 or <.001. Parental bonding style and scores in the care and overprotection dimensions were also correlated. The only parental bonding style in which correlations were found was in affectionless control. Correlations were more common in cases of neglect compared to abuse.

CONCLUSIONS

In this research we found important differences in terms of parental attachment and childhood trauma between patients with SQZ and BD, compared with controls of the same gender and age.

Parental bonding, depression, and suicidal ideation in medical students

Background

The psychological condition of university students has been the focus of research since several years. In this population, prevalence rates of depression, suicidal ideation, anxiety disorders and substance abuse are higher than those of the general population, and medical students are more likely to have mental health issues than other students.

Aims

This study deals with the psychological condition of medical students, with a focus on correlations between depression, suicidal ideation and the quality of the perceived parenting style. Gender differences were also considered.

Methods

A cross-sectional study was conducted on a population of medical students, with an online questionnaire consisting of a personal data sheet for demographic and anamnestic data, and of three self-rating scales: the Beck Depression Inventory II (BDI-II), for the screening of depressive symptoms; the Beck Hopelessness Scale (BHS), to assess suicidal ideation; the Parental Bonding Instrument (PBI), to investigate the memory of the attitude of one’s parents in the first 16 years of life. Two main affective dimensions were considered by PBI: “care” (affection and empathy) and “protection” (intrusiveness, controlling and constraint). Four different patterns of parenting styles are so evidenced: Neglectful Parenting (low care/low protection), Affectionless Control (low care/high protection), Optimal Parenting (high care/low protection), and Affectionate Constraint (high care/high protection).

Results

Overall, 671 students (182 males and 489 females) participated. Females, compared to males, experienced more distress and self-injurious behaviors, while males experienced more drugs or alcohol abuse. The BHS and BDI-II scores correlated positively with the PBI score for “protection” and negatively with that for “care.” Affectionless Control and Neglectful Parenting were associated with higher medians of BHS and BDI-II scores.

Conclusion

The study confirms that the undergraduate medical student population has higher prevalence of depression and suicidal ideation than those detectable in the general population (respectively, 50.2% and 16.7% vs. 15–18% and 9.2%) and that some specific parenting styles correlate with these two clinical variables. The impact of Affectionless Control and Neglectful Parenting on suicidal ideation and depressive symptomatology was more pronounced in females than in males. For males, the role of the father seemed to have less impact on the affective roots of suicidal thoughts and depression.

From pregnancy to 3 months after birth:the beginning of mother-infant relationship from a maternal perspective

BACKGROUND

An early positive mother-child relationship is a central factor in the development of a psychologically balanced personality. The study aims to identify risk and protective factors for the development of a balanced maternal-infant postnatal attachment. We explored the association between maternal-infant attachment and prenatal and postnatal variables potentially implicated in the development of this early bond: maternal-foetal prenatal attachment, social support, memories of parental care, romantic attachment, dyadic adjustment, parity, breastfeeding, planning pregnancy, woman's and infant's age, and difficulty of delivery.

METHODS

123 pregnant women participated in the longitudinal study; they were assessed on the MAAS, PBI, ECR-R, MSPSS (t1: pregnancy), MPAS (t2: 3-months postnatally), DAS , and CES-D (t1, t2).

RESULTS

Four significant predictors of maternal-infant postnatal attachment (MPAS) emerged: maternal-foetal prenatal attachment (β = 0.379, p < .001), anxiety in the romantic relationships (β=-0.237, p=0.019), prenatal and postnatal dyadic adjustment (t1, β=-0.323, p=0.025 ;t2, β=0.329, p=0.014) in the couple's relationship. These variables explained 20.2% of variance in mother-infant attachment (R²adjusted=0.202).

DISCUSSION

The study highlights associations of maternal-infant postnatal attachment with prenatal and postnatal relational variables and with other variables related to the woman's reproductive and pregnancy history. Clinical attention to these factors could help protect the well-being of mother and child.

Basic Family Relations, Parental Bonding, and Dyadic Adjustment in Families with a Member with Psychosis

The aim of the current study is to describe and explore basic family relations, parental bonding, and dyadic adjustment in families with offspring diagnosed with a psychotic disorder. The sample was made up of 120 participants, 60 in the clinical group (GCL) and 60 in the comparison group (GCP). All participants were assessed using the basic family relations evaluation questionnaire (CERFB), the parental bonding instrument (PBI), and the dyadic adjustment scale (DAS). The results showed differences between the clinical and comparison groups in terms of perceptions of basic family relations, dyadic adjustment and parental bonding. The clinical group recorded less favorable results for all of these variables. More specifically, the study observed significant differences between the groups in parental function, overprotection and caring. This study deepens our understanding of how family assessment and relational diagnoses can serve as prevention and intervention tools for families affected by a psychotic disorder.

A Persian version of the parental bonding instrument: factor structure and psychometric properties

The Parental Bonding Instrument (PBI) is a widely used self-report measure for quantifying key parenting styles as perceived by the child during its first 16 years. While its development study identified two key parental dimensions, subsequent studies have variably confirmed those two or argued for one or more additional parental constructs. We developed a Persian translation of the PBI and administered it to a sample of 340 high school students. The construct validity of the Persian PBI was examined by Exploratory Factor Analysis while Confirmatory Factor Analysis was used to identify the most adequate model. Analyses of the Persian PBI favored a four-factor model for both parental forms. The Persian PBI has a factorial structure consistent with constructs identified in western cultures, as well as high internal consistency and test-retest reliability. Multivariate analyses indicated significant differences between boys and girls across some factors. The PBI appears an acceptable and appropriate measure for quantifying parent-child bonding in Iranian samples.

Patterns and correlates of expressed emotion, perceived criticism, and rearing style in first admitted early-onset schizophrenia spectrum disorders

The aim of this study was to assess patterns and correlates of family variables in 31 adolescents treated for their first episode of a schizophrenia spectrum disorder (early-onset schizophrenia [EOS]). Expressed emotion, perceived criticism, and rearing style were assessed. Potential correlates were patient psychopathology, premorbid adjustment, illness duration, quality of life (QoL), sociodemographic variables, patient and caregiver "illness concept," and caregiver personality traits and support. Families were rated as critical more frequently by patients than raters (55% vs. 13%). Perceived criticism was associated with worse QoL in relationship with parents and peers. An adverse rearing style was associated with a negative illness concept in patients, particularly with less trust in their physician. Future research should examine perceived criticism as a predictor of relapse and indicator of adolescents with EOS who need extended support and treatment. Rearing style should be carefully observed because of its link with patients' illness concept and, potentially, to service engagement and medication adherence.

Blunted cortisol awakening response in men with first episode psychosis: relationship to parental bonding

Early life adversity has been associated with an increased risk for the development of mental health problems, including psychotic disorders, perhaps mediated by a changed regulation of the Hypothalamic Pituitary Adrenal (HPA) axis. Aim of the present study was to confirm our previous finding of an attenuated cortisol awakening response (CAR) in men with first episode psychosis (FEP) and to explore a possible link between a blunted CAR and early adversity as indicated by perceived parental bonding. Fifty-eight patients (38 men, 20 women; mean age 23.25±3.86) with a FEP and 33 healthy community controls (16 men, 17 women; mean age 22.91±3.64) participated in the study. Saliva samples for assessment of the CAR were collected immediately, 30 and 60min after awakening. Complete cortisol samples were available in a reduced sample of 56 patients (37 men) and 30 controls (13 men). Parental bonding during the first 16 years of life was assessed retrospectively with the Parental Bonding Inventory. Results showed a significantly blunted CAR in male compared to female patients, confirming our previously reported findings. We also found a lower CAR in the total FEP group compared to controls, which failed to reach significance after controlling for time of awakening. A significantly lower percentage of patients than controls reported optimal maternal parenting. Within the patient group, significantly fewer male than female patients reported optimal maternal and paternal parenting. Only in patients, unfavorable paternal parenting was related to a blunted CAR. Dysregulation of the HPA axis in male patients might be a consequence of non-optimal parenting and contribute to the less favorable course of psychosis in men compared to women.

Sub-optimal parenting is associated with schizotypic and anxiety personality traits in adulthood

Part of the variation in personality characteristics has been attributed to the child-parent interaction and sub-optimal parenting has been associated with psychiatric morbidity. In the present study, an extensive battery of personality scales (Trait Anxiety Inventory, Behavioural Inhibition/Activation System questionnaire, Eysenck Personality Questionnaire-Revised, Temperament and Character Inventory, Schizotypal Traits Questionnaire, Toronto Alexithymia Scale) and the Parental Bonding Instrument (PBI) were administered in 324 adult healthy males to elucidate the effects of parenting on personality configuration. Personality variables were analysed using Principal Component Analysis (PCA) and the factors "Schizotypy", "Anxiety", "Behavioural activation", "Novelty seeking" and "Reward dependence" were extracted. Associations between personality factors with PBI "care" and "overprotection" scores were examined with regression analyses. Subjects were divided into "parental style" groups and personality factors were subjected to categorical analyses. "Schizotypy" and "Anxiety" were significantly predicted by high maternal overprotection and low paternal care. In addition, the Affectionless control group (low care/high overprotection) had higher "Schizotypy" and "Anxiety" compared with the Optimal Parenting group (high care/low overprotection). These results further validate sub-optimal parenting as an important environmental exposure and extend our understanding on the mechanisms by which it increases risk for psychiatric morbidity.

Psychometric properties of the Chinese version of the Parental Bonding Instrument

BACKGROUND

The Parental Bonding Instrument (PBI) is a widely used assessment tool for measuring parental characteristics that affect parent-child bonds. The measure was developed for and has been most administered in Western populations. Psychometric analyses have yielded discrepant results as to whether the PBI is best represented by a two-factor model (care and overprotection) or a three-factor model (care, overprotection, and autonomy).

OBJECTIVES

Little is known about how the PBI performs in Chinese samples, and there is limited data from Eastern populations as a whole. The purpose of this study is to: (1) explore the data and identify the underlying structural model that best fits the Chinese culture, and (2) to further compare the factor structure that emerges in a Chinese sample with that which has emerged in other Eastern cultures (i.e., Japanese) and Western countries.

METHODS

The present study investigated the psychometric properties of a Chinese translation of the PBI among a sample (N=1417) of mothers of kindergarten children. Confirmatory factor analysis was used to identify the most adequate model.

RESULTS

Results supported a four-factor model that included an indifference factor (χ(2)/df<3.0; RMSEA<0.06; SRMR<0.08). Both the two-factor and three-factor models performed poorly (χ(2)/df>5.0; RMSEA>0.08; SRMR>1.0; CFI<0.90 for both). In this sample, use of a Chinese translated version of the PBI was successful. Support for the four-factor model is consistent with findings from previous studies of Eastern populations and discrepant from those among Western samples.

CONCLUSIONS

The indifference factor may reflect aspects of parenting specific to Eastern cultures, which tend to value group cohesion over individualization and independence. More research is needed to determine whether these findings are generalizable to all Eastern countries and whether aspects of Chinese culture (e.g., the single-child law) produce unique effects that may impact PBI administration in China.

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.

Childhood antecedents of adult sense of belonging

Sense of belonging has been proposed to be a basic human need, and deficits in sense of belonging have been linked to problems in social and psychological functioning. Yet, there is little evidence about what early life experiences contribute to sense of belonging. The purpose of this study was to examine potential childhood antecedents of adult sense of belonging. The sample consisted of 362 community college students ranging in age from 18 to 72 years, with a mean age of 26 years. Measures included the Sense of Belonging Instrument, the Parental Bonding Instrument, and the Childhood Adversity and Adolescent Deviance Instrument. Multiple regression analysis was used to correlate childhood antecedents with adult sense of belonging. The final reduced model included 12 variables, which accounted for 25% of the variance in sense of belonging. Significant positive antecedents with a relationship with sense of belonging were perceived caring by both mother and father while growing up, participation in high school athletic activity, and parental divorce. Significant negative variables with a relationship with sense of belonging included perceived overprotection of father, high school pregnancy, family financial problems while growing up, incest, and homosexuality. Knowledge of these factors should influence interventions with families regarding child-rearing and parenting practices, mediating the effects of crises during childhood such as divorce and teen pregnancy, and the interpersonal growth needs of teenagers.

SOCIAL SUPPORT, LONELINESS AND FRIENDSHIP PREFERENCE AMONG BRITISH ASIAN AND NON-ASIAN ADOLESCENTS

This paper aims to investigate the support-seeking behavior of adolescents (14 and 15 years) of South Asian and other backgrounds, the association between friendship choice and perceived feelings of loneliness, and the complex inter-relationship between these variables. Standardized psychological measures were administered to a sample of 824 Asian and other adolescents. The findings for a weighted sample of 651 show that Asian adolescents have higher levels of perceived feelings of loneliness and a lower level of preference for mixed-ethnic friendship than their non-Asian counterparts. A significant difference is also obtained on the support-seeking behavior between Asian and non-Asian adolescents. The development perspectives of the findings that are implicated in the socialization process are discussed.

Further results on the reliability of the Parental Bonding Instrument (PBI) in an Italian sample of schizophrenic patients and their parents

The reliability of the Italian version of the Parental Bonding Instrument (PBI) was assessed in a group of 26 schizophrenic patients and their parents. In both groups, internal consistency indices were satisfactory and mean PBI scores at test and retest were stable. The test-retest reliability coefficients for the PBI scales of parents ranged from .65 to .67, those of the patients from .32 (paternal-protection score) to .67 (maternal-care score). The less satisfactory test-retest reliability of patients' paternal protection score was due to minor intra-category rather than inter-category variations in their ratings. This suggests difficulties with a four-point rating scale, which might depend partly on the generally poor schooling of the sample, but it may also reflect uncertainty of schizophrenic patients concerning fathers' controlling behavior. Further studies should pay attention to this factor. Patients' PBI mean scores are compatible with an affection-less control rearing style, while those of their parents, characterized by similar poor care but less control, are consistent with a pattern of weak parental bonding.

[Parental bonding as a predictive factor for the development of adult psychiatric disorders]

OBJECTIVE

To asses the capacity of the Parental Bonding Instrument (PBI) to discriminate between normal subjects and clinical samples and between with different psychiatric diagnosis.

DESIGN

The present paper analyzes the studies published between 1979 and 1995, which have used the PBI in normal subjects and clinical samples and have reported the respective means and standard deviations obtained on the two PBI dimensions: affection and control. Multiple comparisons were carried out between the mean scores of affection and control of: 1) samples with the same psychiatric diagnosis (intragroup comparison); 2) samples with different psychiatric diagnoses (intergroup comparison); 3) normal subjects and clinical samples.

RESULTS

Of the 46 studies with normal and clinical subjects, 23 studies were selected for the analysis, reporting means and standard deviations and specifying the diagnostic criteria. Samples with the same psychiatric diagnosis had similar affection and control scores. With the exception of bipolar affective disorders and avoidant personality disorders, the prevalent parental style was for all diagnostic groups the affectionless control style. Within the affectionless control style, the PBI discriminated between panic attacks, borderline personality and drug addiction but not between schizophrenia, unipolar depression and anxiety disorder. The PBI discriminated also between normal subjects samples and samples with anxiety disorder, schizophrenia, bipolar affective disorder, personality disorder and drug addiction respectively.

CONCLUSION

The results confirm previous suggestions from single studies that the perceived parental style as measured by the PBI can be considered a good predictor for the presence of psychiatric disorders excluding panic attacks, avoidant personality disorders and unipolar affective disorders. Although the different diagnostic groups do not differ in their perceived parental style (affectionless control), significant differences between some diagnostic groups within this category suggest that the PBI might have some specificity as well.

Perceived parental rearing behaviour in patients with a schizophrenic disorder and its relationship to aspects of the course of the illness

A total of 57 patients of both sexes (27 women and 30 men) with a definite diagnosis of a schizophrenic disorder completed the EMBU, a Swedish instrument designed to assess the experience of parental behaviour, that has been extensively used in cross-national studies. As in previous studies in different patient populations, three factors, 'rejection', 'emotional warmth' and 'overprotection', have been taken into account. The results obtained in the patient group were compared with those obtained in a control sample of healthy Swedish subjects. Schizophrenic patients rated both parents higher than controls on the factor 'rejection', and rated their mothers lower on the factor 'emotional warmth'. No correlation was found between EMBU score and age at the first hospitalization, or number of rehospitalizations within 1 year after discharge at the index episode. The present results cross-validate those obtained by other authors in other cultural settings, and suggest that negative experiences of parental rearing might be an important factor contributing to the development of 'vulnerability' in a person who will subsequently develop a schizophrenic disorder.

Construct validation in adolescents of the brief current form of the Parental Bonding Instrument

We have reported elsewhere the development of a brief version of the Parental Bonding Instrument (PBI), which we have called the Parental Bonding Instrument-Brief Current form (PBI-BC), for use in survey research in adolescent samples. It was shown in that report that PBI-BC retained the factor structure of the original instrument. The structure remained stable in adolescents' ratings of their mothers and their fathers. Given the evidence of a relationship between the dimensions from the original scale and psychopathology, it was expected that the PBI-BC would be similarly related to measures of psychopathology, namely, that there would be a set of positive correlations between the perceived parental bonding styles of high control and low autonomy-giving and measures of pathology, with a negative relationship between pathology and perceived parental styles of high care and low rejection. In addition, the present study explored the relationships between perceived parental styles and bipolar positive and negative self-concept measures, with the expectations that high control and low autonomy would be associated with more negative self-concept and that high care and low rejection would be associated with more positive self-concept. The results generally confirmed these expectations, suggesting that the brief instrument has adequate construct validity and would be particularly useful as a brief index in studies of adolescents.

Attributions of symptomatology: an exploration of family factors associated with expressed emotion

This study explored family factors associated with Expressed Emotion (EE) in families with a member diagnosed with schizophrenia. Drawing on an attributional model of expressed emotion it was predicted that high EE relatives would have less knowledge of the illness and would attribute negative symptoms to the personality, rather than the illness, of the sufferer. Thirty-one caregivers of schizophrenic patients were interviewed. Results indicated that EE status was related to knowledge, coping and causal attributions of negative symptoms. Low EEs, as compared with High EEs, tended to have more knowledge of the illness and to cope better with the patient, and were less likely to attribute the cause of negative symptoms to the sufferer's personality. Support was therefore obtained for the utility of an attributional model in attempting to understand the determinants of levels of EE.

Relationship between expressed emotion and family burden in psychotic disorders: an exploratory study

This study explored the relationship between level of expressed emotion (EE) and level of family burden in 20 families of individuals with psychotic disorder. Results indicated that a relationship between EE and family burden did exist, but it appeared to be strongly influenced by demographic and illness-related variables. The usefulness of the 5-min speech sample method of assessing EE was limited by the aversion of some family members to being videotaped and by denial of patient symptoms by some relatives. Other methodological weaknesses are discussed. The relationship between demographic and illness-related variables and level of EE needs further exploration.

Understanding family variables in outcome research in schizophrenia

Outcome studies in schizophrenia research consistently show the importance of family variables in predicting patient relapse. The concept of expressed emotion (EE) is clinically relevant, though concerns remain about its precise meaning. The history of the EE studies is reviewed in the light of other family research, and an alternative model of family emotional environment is proposed. A number of clinical implications are considered.

Factorial validity of the EE scales

High 'expressed emotion' (EE) has been held to be predictive of a poor course in patients with schizophrenia, a finding that has emphasized the predictive validity of the EE measure. We review appropriate research examining properties of the EE measure to suggest that, in particular, little is known about the construct validity of the EE measure. We report a longitudinal study examining three measures of parental style (EE; Parental Bonding Instrument or PBI; and interviewer ratings). By comparing EE scale scores with ratings derived by an interviewer we find support for the accuracy of the process generating EE scale scores, and by factor analytic techniques we examine the factorial (construct) validity of the EE scales. A principal components analysis suggested two other dimensions of relevance in parents involved with a schizophrenic member (vigilance, and acceptance of illness in their child) which may be of value in predictive studies. We examined the capacity of interviewer-generated scores (as a simple clinical rating) and factor scores (as central constructs) to predict the course, and were unable to discriminate 'relapsers' and 'non-relapsers' with either predictor.