School of Psychology, University of Birmingham and Early Intervention Service
School of Psychology, University of Birmingham, UK
Correspondence: Dr Paul Patterson, ED:IT, Early Intervention Service, 97 Church Lane, Aston, Birmingham B6 5UG. E-mail: patterpj{at}bham.ac.uk
* Paper presented at the Third International Early Psychosis Conference,
Copenhagen, Denmark, September 2002.
![]() |
ABSTRACT |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Method Fifty patients and key carers were followed-up over 9 months and their appraisals of loss and burden were measured in relation to the evolution of high emotional overinvolvement (EOI) and critical (CC) relationships.
Results The appraisal of loss was linked to high EOI but not high CC relationships at baseline. Loss reduced by 9-month follow-up in those changing from high EOI to high CC or low EE. Subjective burden of carers was linked to loss but not to EE status. Patients and relatives appraisals of loss were strongly correlated, particularly in high EOI relationships. Longer duration of untreated psychosis was associated with high CC.
Conclusions The results are consistent with Bowlbys attachment theory, where EOI and coercive criticism may be understood as adaptive reactions to perceived loss. Implications for family intervention in first-episode psychosis and the prevention of high EE are discussed.
![]() |
INTRODUCTION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Of those that have, some support has been found for an attributional model of EE (Brewin et al, 1991; Barrowclough & Tarrier, 1992). Higher levels of criticism have been associated with relatives perceiving the cause of patients behaviours and symptoms as more personal to and controllable by the patient (Brewin et al, 1991; Weisman et al, 1998), more troublesome behaviours in patients (Boye et al, 1999) and failure to engage in productive activity (King et al, 2003), whereas emotional overinvolvement (EOI) was linked to more anxious and depressive symptoms and less aggressive and uncritical behaviour perceived by relatives (Bentsen et al, 1996, 1998).
Barrowclough & Tarrier (1992) suggest that relatives high in critical relationships (CC) may be displaying coercive attempts to restore behaviour mediated by beliefs of controllability and internal attributions. Emotional overinvolved responses are perhaps less clearly understood but carers who are mothers, single and those who perceive anxiety and depression symptoms in the patients are more likely to be high in EOI (Stubbe et al, 1993; Bentsen et al, 1996), suggesting a transactional process may be operating.
Models of the transactional process between patients and carers explore how each adapts to changes in mental life and behaviour, to the diagnosis and its treatment, and several studies of EE have employed Lazarus & Folkmans (1994) stress appraisal framework. Birchwood & Cochrane (1990), Smith et al (1993), Barrowclough & Parle (1997) and Scazufca & Kuipers (1999) found carers high in EE perceive greater threat, lower control, and report higher distress. One possible form of threat for relatives may be a perceived loss of cherished roles, goals or relationships associated with the unwell family member. Whereas the components of the grieving process have previously been discussed in relation to living with psychosis (Olshansky, 1962; Atkinson, 1994; Davis & Schultz, 1998) they have seldom been explored quantitatively in response to psychosis (Miller et al, 1990; Atkinson, 1994), or in association with EE (Patterson et al, 2000; Raune et al, 2004).
The present study follows-up a sample of first-episode patients and their relatives to explore the appraisals associated with components of EE and focuses on the following questions concerning the appraisal of loss early in the course of psychosis:
![]() |
METHOD |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Assessments
Expressed emotion
Relatives EE level was assessed using the Camberwell Family
Interview (CFI; Vaughn & Leff,
1976). A relative was rated as high in EE if they scored 6 or
higher in the criticism (CC) sub-scale; 3 or higher in the emotional
overinvolvement (EOI) scale or had any score for hostility (H). P.P. was
trained in the assessment of EE to acceptable levels of reliability (overall
EE, =0.84; CC, r=0.94; H,
=0.85; EOI,
=0.85). A random
sample of ten completed CFI interviews from the present study were later rated
for reliability and these were also found to have acceptable levels of
reliability on overall EE (
=0.80); CC (reliability intraclass
coefficient; ICC=0.74); H (ICC=1.0); EOI (ICC=0.88).
Family burden
The Experience of Caregiving Inventory (ECI;
Szmukler et al, 1996)
was used to measure salient aspects of caregiving. The ECI is a 66-item
questionnaire with ten sub-scales measuring eight negative aspects of
caregiving (difficult behaviours; negative symptoms; stigma; problems with
services; effects on the family; the need to provide back-up; dependency;
loss) and two positive aspects (rewarding personal experiences; good aspects
of the relationship with the patient). The negative sub-scales are summed to
produce a total negative burden scale. The scale has excellent
psychometric properties (Szmukler et
al, 1996).
Loss reactions
Loss was assessed in relatives and patients using the mental illness
version of the Texas Revised Inventory of Grief (TRIG;
Miller et al, 1990).
Originally developed to assess unresolved loss in bereavement
(Faschingbauer et al,
1977), it was adapted by Miller et al to assess loss
reactions in relatives of the mentally ill. Items in the TRIG are focused on
the loss of aspirations and cherished hopes for the individual
and intrusive memories of the individual as he or she used to be. For example,
items include: I cry when I think how he used to be before the
illness, I am preoccupied by thoughts about [he or she] could have been
if not for the illness. The measure therefore comprises a cognitive
component, the appraisal of loss, and an emotional component, the distress
associated with this appraisal.
The 16 items that comprise the scale are each rated by the individual on a
five-point scale from completely true to completely
false. The scores are summed. The scale has high internal consistency
(Cronbachs =0.92; Miller
et al, 1990). For this study we also assessed parallel
loss reactions in patients: to do this we adapted each item with a simple
change of pronoun (e.g. I am preoccupied with the thought of how
I could have been if not for the illness).
Depression
The Calgary Depression Scale for Schizophrenia is an interview-based scale
measuring depressed mood, suicidal thinking, self-deprecation and
hopelessness. It is in widespread use in schizophrenia, and benefits from
minimal overlap with negative symptoms
(Addington et al,
1992). In this study we also used it to measure depression in
relatives to enable a direct comparison between relatives and patients.
![]() |
RESULTS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Among those successfully followed-up, 30 of the relatives were parents (76.8%) of which 17 (43.5%) represented single-parent households. There were six partners (15.3%) and three siblings (7.7%). Relatives mean age was 43.9 years (s.d.=11.2). The patient sample of 24 males and 15 females with average age at illness onset of 22.8 years (s.d.=5.7) included 28 White (71.7%), 6 Asian (15.4%) and 5 Black or mixed race (12.8%) individuals. The majority of patients (34, 85.6%) returned to live in the family home for the duration of the follow-up period, with the other 5 remaining in regular contact (mean=three times weekly) with their key relative.
Stability and change in expressed emotion
Expressed emotion at the first episode
Thirty relatives were high EE (60%) and 20 (40%) low EE at the first
episode. Of the 30 relatives high in EE, 16 were high EOI, 11 high CC and 11
high H (with 9 of these high CC and H, 1 high EOI and CC, 1 high EOI and H).
The correlation between CC and EOI was r-0.12 (NS). High CC carers
had relatives with a longer duration of untreated positive psychotic symptoms
prior to first treatment (low CC=26.4 days, high CC=85.4 days,
F(1,37)=5.99, P<0.05). Expressed emotion status at index
and follow-up was significantly but moderately correlated (r=0.48,
P<0.01), as was CC (r=0.55) and EOI (r=0.66) but
not H (r=0.13), suggesting considerable stability but also
intra-individual change.
There was a considerable change in overall EE status over the follow-up period, with 30.7% of the relatives obtaining a different EE rating from the initial measure. This was predominantly made up of 42% of the initially high EE relatives resolving to low EE, whereas only 13% of the initially low EE relatives resolved to high EE. The individual sub-scales of the CFI showed clear differences in the resolution of EOI and CC in those carers (n=39) followed-up after 9 months. Of 16 carers initially high in EOI, 5 (32%) remained high at follow-up, whereas of 9 carers initially high in CC, 5 (56%) remained high CC. None of those initially high in CC changed to or acquired high EOI at follow-up; this compares with 6 of the 16 originally high in EOI who were rated high CC at follow-up and an additional 2 who remained high EOI also rating high in CC at follow-up.
Loss
Relatives loss
The appraisal of loss in key relatives was high at follow-up and similar to
levels reported in bereaved individuals
(Miller et al, 1990). Atkinson (1994), using the
TRIG, found that parents who had lost children through death displayed very
high levels of initial perceived loss, but this greatly reduced over time
(mean=28.8, s.d.=3.6) and was significantly lower than a matched group of
parents who had an offspring with schizophrenia (mean=53.8, s.d.=4.1). In the
present study, there was a significant reduction in carers loss
appraisals from the first episode (52.5, s.d.=11.6) to follow-up (45.0,
s.d.=10.6), t=4.7; P<0.001, although relatives
perceived losses at index and follow-up were significantly but moderately
correlated (r=0.55, P<0.01), suggesting considerable
intra-individual variability over time against this general background of
sustained feelings of loss.
Patients loss
At the first episode, patients appraisals of loss was high (50.3,
s.d.=11.4) and remained high at follow-up (47.6, s.d.=8.7), suggesting that
the impact of psychosis engenders similar loss reactions in patients and key
carers over time. Although at the baseline there were no significant
correlations between relatives and patients loss (TRIG) scores,
by follow-up a significant correlation emerged which was very strong among
high EOI relationships (Table
1).
|
Expressed emotion and loss
There was no overall difference between high and low EE relatives in loss
(TRIG) scores at the first episode; however, high EOI relatives reported
significantly higher loss scores than low EOI ones whereas the high CC
relatives scored significantly lower than low CC. Direct comparison of those
high in EOI only with those high in CC only confirmed that it was the high EOI
group who appraised greater loss (P<50.001).
Is there a link between EE and loss?
Those relatives with initially high levels of EOI which resolved to high CC
(n=8) showed a significant reduction in loss from 59.6 (s.d.=8.5) to
43.4 (s.d.=10.2), t=8.2, P<0.001; similarly, those
initially high in EOI resolving to low EE (n=5) also showed a
reduction in loss from 57.4 (s.d.=11.2) to 42.2 (s.d.=15.5), t=4.1,
P=0.014. Those who remained high EOI at follow-up showed no reduction
in loss from onset (62.7) to follow-up (58.7). By contrast, the high CC
relatives, who started at onset with the lowest loss scores, remained low at
follow-up (these relatives either remained high CC or resolved to low EE).
In summary, there was no link with overall EE and loss but very different patterns of loss were observed between high CC and high EOI relatives:
Burden
At the first episode
There were no significant differences between high and low EE relatives on
subjective burden (ECI). Looking at the subscales, high EOI relatives reported
higher burden scores (84.5, s.d. 28) than low EOI (66.4, s.d.=17.9),
P<0.01. High CC relatives recorded lower ECI scores (64.1,
s.d.=20.7) than low CCs (76.3, s.d.=24.4) but this was not significant.
Relatives loss was correlated with subscales of burden especially the effects on the family and total negative burden and this was stronger at follow-up with the addition of problems with services and dependency.
At follow-up
High EE relatives perceived significantly higher levels of total negative
burden, F(2, 37)=10.85, P=0.002. This extended to one of the
positive scales (positive personal experiences) and suggests that many aspects
of the relationship between relatives and patients are more intensely focused
on by high EE relatives. Analysis of the EE sub-scales revealed that this
effect was entirely due to the high EOI relatives who recorded nearly 50%
higher perceived burden (ECI) scores than low EOI, with the loss sub-scale
exercising particular influence (for ECI see
Szmukler et al,
1996). Again, no differences emerged between those high
v. low in CC. Direct comparison between those relatives high in EOI
only and high in CC confirms that it is the high EOI group who experience a
greater burden
(P<50.01).
|
Loss and burden
Overall, there was no significant reduction in ECI (burden) scores from
onset (73.7, s.d.=25.7) to follow-up (69.4, s.d.=29.6), nor did it track any
of the movements in the EE sub-scales. Loss was, however, highly correlated
with ECI scales Total Negative Burden (P<0.05);
Effect on the Family (P<0.01) and Loss
(P<0.01) at both onset and follow-up and additionally with
Dependency (P<0.001) and Problems with Services
(P<0.01) at onset. This suggests that appraisals of burden may
reciprocate with the intensity of perceived loss independently of EE levels in
carers.
Depression
Expressed emotion
There was no relationship between relatives or patients
depression and EE at onset or follow-up. This was also true of the sub-scales,
although high EOI relatives scores were higher on the Calgary
Depression Scale for Schizophrenia (CDS) at onset (7.8 v. 5.7, NS)
and at follow-up, where this approached significance, 7.1 (s.d.=4.4)
v. 3.9 (s.d.=3.8); P=0.06.
Loss and burden
At follow-up, relatives depression correlated (r=0.44;
P<0.01) with loss (TRIG) and with burden (r=0.43;
P<0.01). In order to determine the principal predictor of
depression in relatives at follow-up, a multiple regression analysis was
conducted with CDS as a dependent variable and relatives TRIG, ECI and
EOI as independent variables. A step-wise method of entry and removal was
used. Only loss was chosen (R=0.44; ß=0.44,
P<0.005).
![]() |
DISCUSSION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Methodological issues
The sample employed in the present study is comparable with samples
employed by other researchers in this area (e.g.
Scazufca & Kuipers, 1996), particularly first-episode research
(Stirling et al,
1993; Raune et al,
2004). The subgroup analyses, particularly those moving from high
EOI to high CC, were based on small numbers, although highly significant, and
accordingly must be treated as preliminary. The cross-sectional comparison of
the EOI and CC scales were more robust, being based on larger samples and the
relationships with loss were observed at both index and follow-up suggesting
that this was not an isolated observation.
The proportion of families from each ethnic group broadly reflected the local demographic profiles, and as such are representative of the areas in which the study was carried out. The findings may not, however, generalise to settings where the ethnic profile is very different. Hashemi & Cochrane (1999) found different EE profiles in British Asian and White samples, with Muslims more likely than Whites to be rated as high EE. In the present study, only three of the follow-up families were Muslim (one parental, two siblings), with low levels of EE at both time points in two of these and high at onset/low at follow-up in the other. The sample was not epidemiologically based (in common with most other EE studies) which will constrain its generalisability to an unknown degree. Eight out of ten families consented to the follow-up comparable with similar studies and no evidence of selective attrition could be found. Overall, the internal and external validity of the study was felt to be sufficiently robust, with the exception of results from some of the subgroup analyses that should be taken as preliminary.
Expressed emotion and loss
These findings suggest that high EE relationships involving high EOI and CC
may have an adaptive function in assisting the relative to respond to the
crisis of a family member developing a psychosis. It may be speculated that
loss motivates the EOI relationship whose over-controlling
qualities may be construed as an attempt to restore the status quo and to
mitigate the loss, but what of the inverse relationship between criticism and
loss? A clue here may lie in the observation that some EOI relationships
evolve to critical ones; suggesting that high CC relationships may be
fundamentally underpinned by concern. The accompanying reduction of loss may
be adaptive for relatives in easing the distress of an apparently unresolvable
situation. Bowlbys
(1980) attachment theory
demonstrates that coercive criticism is a natural reaction to any perceived
loss, having the aim of re-establishing what has been lost, such
as the pre-existing status quo in the relationship. Rather than
suggesting that high EE families are dysfunctional or maladapted, attachment
theory suggests that it is normal for a parent or close relative of a patient
to express their concerns, or even a reflex affectional
response, through criticism. This supports Hooleys view
(1986) that high EE may be
adaptive, and it is the low EE response which may in fact be unusual when
faced with a psychosis. It could be that low EE is reached if there is already
experience of mental illness in the family, where coercive measures have been
previously tested and rejected, or perhaps in response to a psychosis that has
had a long and insidious development, where adaptation within the family has
already taken place over many months or years during the prodrome phase. In
situations where coercive criticism does not appear to be working, hostility
may be expressed which can be conceptualised as the expression of extreme
frustration when coercive criticism constantly fails in its objective. The
lack of correlation of hostility in relatives from onset to follow-up suggests
that this response is less a typical response pattern of relatives and more
likely to be reactive to current situational factors (e.g. the frustration at
the patients lack of response to coercion).
Expressed emotion and family burden
The finding that high EE is associated with higher burden in relatives
supports previous findings by Smith et al
(1993) and Scazufca &
Kuipers (1996,
1998). In the present study we
found that burden was a strong feature mainly of the high EOI relationship. It
has previously been found that higher burden in relatives is associated with
avoidant coping styles and that it is those relatives high in EOI who tend to
adopt avoidant coping strategies (Scazufca
& Kuipers, 1999). This, along with the large number of
relatives high in EOI at onset, may help to explain the finding that burden in
this sample was mainly associated with relatives high in EOI and not those
high in CC at both index and follow-up. The levels of distress in relatives
may also be different at the first episode than later in the course of
illness. Tennakoon et al
(2000) found that levels of
psychiatric caseness among carers was only 12% in a
first-episode sample, whereas higher rates have been reported among more
chronic samples (e.g. 58% in Budd et
al, 1998). The present findings that relatives high in EOI at
the first episode tended to be more depressed suggests that EOI and CC warrant
further investigation as separate variables. Few studies have examined the
separate sub-scales of EE for associations with burden, although Boye et
al (1999) did find that
patterns of high EOI and high EE at 4.5-month follow-up were associated with
increased levels of family burden, in line with the present findings. Also,
Barrowclough et al
(1996) found that
self-blaming beliefs in relatives were associated with increased
distress, including EOI relationships. Wynne
(1981) has proposed that the
two major components of EEEOI and CCcan be understood as
special forms of attachment/care-giving that are likely to lead to
dysfunctional communicating, problem-solving and intimacy.
Bowlbys work on representational models
(Bowlby, 1980) gives some
support to the idea that attachment styles may link the development of
cognitive biases that in turn may influence the personal interpretation of
events such as loss. Examples of this cognitive bias can be seen in more
recent literature, such as West et al
(1993), who show that
components of anxious attachment can differentiate between psychiatric
out-patients and the general population in a comparison of clinical and
community samples in Canada. Of the components of the attachment scale used,
feared loss explained the greatest proportion of the variance,
suggesting that the inability to feel secure within relationships is an
important correlate of psychiatric disorders and may exacerbate the burden
felt by carers.
Duration of untreated psychosis
The link between longer duration of untreated psychosis (DUP) and high
critical relationships (CC) replicates Macmillan et al
(1986). The overall duration
of DUP in this sample was 63 days (s.d.=96), quite brief compared with many
other studies (e.g. Larsen et al,
2000) although this may be due to the present sample living with
relatives who are more likely to respond to florid symptoms in patients. This
might explain the high rate of EOI seen in this sample, since longer DUP was
associated with more criticism.
Implications
The first major clinical implication is that the early stage of adaptation
to psychosis for family members may often involve a process akin to grieving,
during which time the relative may experience a high level of subjective
burden and is probably less open to, or capable of, integrating
psycho-educational interventions. Linszen et al
(1996) using Falloons
Behavioural Family Therapy in first-episode psychosis
(Falloon et al,
1984), reported that for some relatives this approach interfered
with their need to deal with issues related to loss and the
communication component of the behavioural training upset
carers.
The early phase of psychosis may be a critical period for intervention to prevent high EE, in view of our suggestion that critical responses may be a normal adaptive response to loss involving the reactivation of attachment bonds in the process of searching for the pre-existing relationship (Bowlby, 1980, 1982).
A consideration of the dynamics of grief should play a part in the assessment of carers needs, particularly at this early stage of adaptation to psychosis. Anger, denial, frustration, a search for what has been lost and later acceptance of the new situation are all recognisable as part of the response to loss.
In summary, although the findings were in line with the hypothesised role for loss, they are also open to other interpretations. One possibility is that loss is a proxy measure for depression, i.e. a mood-linked appraisal, which the correlation with depression (0.44) would support. However, the relationships observed between EE and loss were not mirrored in those between EE and depression. A second possibility is that EE itself leads relatives to appraise loss in this way, or that loss is intrinsic to the concept of EE. This interpretation is rendered more problematic by the different pattern of links with loss seen within the high EE (EOI/CC) subgroups and their change with time. If the loss appraisal is not, as we believe, causal, we can at least assert that loss is a major feature of these relationships, particularly EOI relationships, and one shared by patients. Some of these possibilities could be examined with a larger study and a longer follow-up period to allow for more detailed observations in the premorbid phase. A truly prospective study of family relationships during the prodromal phase would be the ideal design but is as yet, unfeasible.
Much of the cognitive literature, while placing great emphasis on the importance of appraisal to the interpretation of events and experiences, takes little account of how these appraisals develop. A deeper understanding of loss reactions in relatives of people with psychosis may help to clarify the aetiology of some EE responses from carers attempting to manage the onset of psychosis in family members.
![]() |
Clinical Implications and Limitations |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
LIMITATIONS
![]() |
ACKNOWLEDGMENTS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
REFERENCES |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Atkinson, S. D. (1994) Grieving and loss in parents with a schizophrenic child. American Journal of Psychiatry, 151, 1137 1139.[Abstract]
Barrowclough, C. & Tarrier, N. (1992) Families of Schizophrenic Patients. Cognitive Behavioural Interventions. London: Chapman and Hall.
Barrowclough, C. & Parle, M. (1997) Appraisal, psychological adjustment and expressed emotion in relatives of patients suffering from schizophrenia. British Journal of Psychiatry, 171, 26 30.[Abstract]
Barrowclough, C., Tarrier, N. & Johnston, M. (1996) Distress, expressed emotion, and attributions in relatives of schizophrenia patients. Schizophrenia Bulletin, 22, 691 702.[Medline]
Bentsen, H., Boye, B., Munkvold, O. G., et al (1996) Emotional overinvolvement in parents of patients with schizophrenia or related psychosis: Demographic and clinical predictors. British Journal of Psychiatry, 169, 622 630.[Abstract]
Bentsen, H., Notland, T. H., Boye, B., et al (1998) Criticism and hostility in relatives of patients with schizophrenia or related psychoses: demographic and clinical predictors. Acta Psychiatrica Scandinavica, 97, 76 85.[Medline]
Birchwood, M. & Cochrane, R. (1990) Families coping with schizophrenia: coping styles, their origins and correlates. Psychological Medicine, 20, 857 865.[Medline]
Brewin, C. R., MacCarthy, B., Duda, K., et al (1991) Attribution and expressed emotion in the relatives of patients with schizophrenia. Journal of Abnormal Psychology, 100, 546 554.[CrossRef][Medline]
Bowlby, J. (1980) Attachment and loss: vol. III. Loss. New York: Basic Books.
Bowlby, J. (1982) Attachment and loss: vol. I. Attachment (2nd edn). New York: Basic Books.
Boye, B., Bentsen, H., Notland, T. H., et al (1999) What predicts the course of expressed emotion in relatives of patients with schizophrenia or related psychoses? Social Psychiatry and Psychiatric Epidemiology, 34, 35 43.[CrossRef][Medline]
Budd, R. J., Oles, G. & Hughes, I. C. (1998) The relationship between coping style and burden in the carers of relatives with schizophrenia. Acta Psychiatrica Scandinavica, 98, 304 309.[Medline]
Butzlaff, R. L. & Hooley, J. M. (1998)
Expressed emotion and psychiatric relapse: a meta-analysis.
Archives of General Psychiatry,
55, 547
552.
Davis, D. J. & Schultz, C. L (1998) Grief, parenting and schizophrenia. Social Science Medicine, 46, 369 379.[CrossRef][Medline]
Falloon, I. R., Boyd, J. L. & McGill, C.W. (1984) Family Care of Schizophrenia. New York: Guilford Press.
Faschingbauer, T. R. (1981) Texas Revised Inventory of Grief Manual. Houston, TX: Honeycomb.
Faschingbauer, T. R., Devaul, R. D. & Ziscook, S. (1977) Development of the Texas Inventory of Grief. American Journal of Psychiatry, 134, 696 698.[Medline]
Hashemi, A. & Cochrane, R. (1999) Expressed emotion and schizophrenia: a review of studies across cultures. International Review of Psychiatry, 11, 219 224.[CrossRef]
Heikkila, J., Karlsson, H., Taiminen, T., et al (2002) Expressed emotion is not associated with disorder severity in first-episode mental disorder. Psychiatry Research, 111, 155 165.[CrossRef][Medline]
Hooley, J. M. (1986) Expressed emotion and depression: interactions between patients and high-versus low-expressed-emotion spouses. Journal of Abnormal Psychology, 95, 237 246.[CrossRef][Medline]
Hooley, J. M., Orley, J. & Teasdale, J. D. (1986) Levels of expressed emotion and relapse in depressed patients. British Journal of Psychiatry, 148, 642 647.[Abstract]
King, S. & Dixon, M. J. (1996) The influence of expressed emotion, family dynamics, and symptom type on the social adjustment of schizophrenic young adults. Archives of General Psychiatry, 53, 1098 1104.[Abstract]
King, S., Ricard, N., Rochon, V., et al (2003) Determinants of expressed emotion in mothers of schizophrenia patients. Psychiatry Research, 117, 211 222.[CrossRef][Medline]
Larsen, T. K., Moe, L. C., Vibe-Hansen, L., et al (2000) Premorbid functioning versus duration of untreated psychosis in 1 year outcome in first-episode psychosis. Schizophrenia Research, 45, 1 9.[CrossRef][Medline]
Lazarus, R. S. & Folkman, S. (1984) Stress, appraisal and coping. New York: Springer.
Leff, J., Kuipers, L., Berkowitz, R., et al (1985) A controlled trial of social intervention in the families of schizophrenic patients: two year follow-up. British Journal of Psychiatry, 146, 594 600.[Abstract]
Linszen, D. H., Dingemans, P. M., Van der Does, A. J., et al (1996) Treatment, expressed emotion and relapse in recent onset schizophrenia. Psychological Medicine, 26, 333 342.[Medline]
Macmillan, J. F., Gold, A., Crow, T. J., et al (1986) Expressed emotion and relapse. British Journal of Psychiatry, 148, 133 143.[Abstract]
Macmillan, F., Crow, T. J., Johnson, A. L., et al (1987) Expressed emotion and relapse in first episodes of schizophrenia. British Journal of Psychiatry, 151, 320 323.[Medline]
Miklowitz, D. J., Goldstein, M. J. & Falloon, I. R. H. (1983) Premorbid and symptomatic characteristics of schizophrenics from families with high and low levels of expressed emotion. Journal of Abnormal Psychology, 92, 359 367.[CrossRef][Medline]
Miller, F., Dworkin, J., Ward, M., et al (1990) A preliminary study of unresolved grief in families of seriously mentally ill patients. Hospital and Community Psychiatry, 12, 1321 1325.
Patterson, P., Birchwood, M. & Cochrane, R. (2000) Preventing the entrenchment of high expressed emotion in first episode psychosis: early developmental attachment pathways. Australian and New Zealand Journal of Psychiatry, 34 (suppl.), S191 S197.[CrossRef][Medline]
Olshansky, S. (1962) Chronic sorrow: A response to having a mentally defective child. Social Casework, 43, 190 193.
Raune, D., Kuipers, E. & Bebbington, P. E.
(2004) Expressed emotion at first-episode psychosis:
investigating a carer appraisal model. British Journal of
Psychiatry, 184, 321
326.
Scazufca, M. & Kuipers, E. (1996) Links between expressed emotion and burden of care in relatives of patients with schizophrenia. British Journal of Psychiatry, 168, 580 587.[Abstract]
Scazufca, M. & Kuipers, E. (1998) Stability of expressed emotion in relatives of those with schizophrenia and its relationship with burden of care and perception of patients social functioning. Psychological Medicine, 28, 453 461.[CrossRef][Medline]
Scazufca, M. & Kuipers, E. (1999) Coping strategies in relatives of people with schizophrenia before and after psychiatric admission. British Journal of Psychiatry, 174, 154 158.[Abstract]
Smith, J., Birchwood, M., Cochrane, R., et al (1993) The needs of high and low expressed emotion families: a normative approach. Social Psychiatry and Psychiatric Epidemiology, 28, 11 16.[CrossRef][Medline]
Stirling, J., Tantam, D., Newby, D., et al (1993) Expressed emotion and schizophrenia: the ontogeny of EE during an 18 month follow-up. Psychological Medicine, 23, 771 778.[Medline]
Stubbe, D. E., Zahner, G. E., Goldstein, M. J., et al (1993) Diagnostic specificity of a brief measure of expressed emotion: a community study of children. Journal of Child Psychology and Psychiatry, 34, 139 154.
Szmukler, G. I., Burgess, P., Herrman, H., et al (1996) Caring for relatives with serious mental illness: the development of the Experience of Caregiving Inventory. Social Psychiatry and Psychiatric Epidemiology, 31, 137 148.[CrossRef][Medline]
Tennakoon, L., Fannon, D., Doku, V., et al
(2000) Experience of caregiving: relatives of people
experiencing a first episode of psychosis. British Journal of
Psychiatry, 177, 529
533.
Vaughn, C. E. & Leff, J. (1976) The measurement of expressed emotion in families of psychiatric patients. British Journal of Clinical Psychology, 15, 157 165.[Medline]
Weisman, A. G., Nuechterlein, K. H., Goldstein, M. J., et al (1998) Expressed emotion, attributions, and schizophrenia symptom dimensions. Journal of Abnormal Psychology, 107, 355 359.[CrossRef][Medline]
West, M., Rose, M. S. & Sheldon, A. (1993) Anxious attachment as a determinant of adult psychopathology. Journal of Nervous and Mental Disease, 181, 422 427.[Medline]
Wynne, L. C. (1981) Current concepts about schizophrenics and family relationships. Journal of Nervous and Mental Disease, 169, 82 89.[Medline]
HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
Psychiatric Bulletin | Advances in Psychiatric Treatment | All RCPsych Journals |