Expressed emotion and attributions in the relatives of bipolar patients: An analysis of problem-solving interactions.

Among the relatives of schizophrenic and depressed patients, high expressed emotion (EE) attitudes are associated with "controllability attributions" about the causes of patients' symptoms and problem behaviors. However, previous studies have judged EE attitudes and causal attributions from the same assessment measure, the Camberwell Family Interview (CFI; C. E. Vaughn and J. P. Leff, 1976). The authors examined causal attributions among relatives of 47 bipolar patients, as spontaneously expressed to patients in family problem-solving interactions during a postillness period. Relatives rated high EE during the patients' acute episode (based on the CFI) were more likely than relatives rated low EE to spontaneously attribute patients' symptoms and negative behaviors to personal and controllable factors during the postillness interactional assessment. Thus, the EE-attribution linkage extends to the relatives of bipolar patients evaluated during a family interaction task. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Measuring expressed emotion: An evaluation of the shortcuts.

The construct of expressed emotion (EE) is a highly reliable and valid predictor of poor clinical outcomes in patients with major psychopathology. Patients are at early risk for relapse if they live with family members who are classified as high in EE. Conventionally, EE is assessed with the Camberwell Family Interview (CFI), a semistructured interview that is conducted with the patient's key relatives. Unfortunately, training in the CFI is difficult to obtain. The CFI is also time-consuming to administer and labor intensive to rate. In this article, the authors discuss alternative ways of assessing EE. They also evaluate the predictive validity of these measures and make recommendations for researchers and clinicians interested in using these assessments. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Causal Attributions About Schizophrenia in Families in China: Expressed Emotion and Patient Relapse.

Previous studies have indicated a robust link between relatives' causal attributions and levels of expressed emotion (EE). However, these studies have primarily been conducted in Western cultures. The current study, conducted in China, examined the spontaneous causal attributions made by 54 relatives of schizophrenia patients during the Camberwell Family Interview. Chinese relatives made few controllable and personal attributions overall. Yet as predicted, highly critical and/or hostile EE relatives attributed patients' negative behaviors to more controllable and personal factors. High EE and controllable attributions positively predicted relapse, whereas personal attributions unexpectedly protected against relapse. EE mediated the effect of controllable, but not personal, attributions on relapse. Relatives' use of a particular Chinese characteristic (narrow-mindedness) was integral to the personal dimension's protective effect. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Expressed emotion. Trait or state?

BACKGROUND: This exploratory study addresses the question of whether expressed emotion (EE) is a response characteristic of the parent (trait) or a parental response to specific circumstances or persons (state). METHOD: Seventeen parents participated in two audiotaped interviews, using modified versions of the Camberwell Family Interview. One interview concerned the child with chronic schizophrenia and the other a well sibling. Subsequent ratings of the EE variables of critical comments (CC), emotional overinvolvement (EOI) and warmth were completed and compared. RESULTS: EE response patterns directed towards patients, as compared with towards siblings, were significantly different on two measures: EOI (P = 0.01) and warmth (P = 0.02). The parents showed significantly more emotional overinvolvement with the child with schizophrenia and significantly more warmth towards the well child. CONCLUSIONS: These data suggest that the EE variables of EOI and warmth are related to the state of child, and the lack of a significant difference in CC suggests that this is a parental trait.     

Expressed emotion and patient-relative interaction in families of recent onset schizophrenics.

Examines the interaction patterns of relatives of young, recent onset schizophrenic patients classified as displaying either high or low expressed emotion (EE) by two measures, the original Camberwell interview method and a recently developed brief method. The former was administered during the hospitalization period and the latter was administered approximately 2 months later when the patient was in the community. Family interactions were coded with an observational coding system that permitted sequential patterns to be analyzed as a function of the EE status of the family. No relation between the Camberwell EE rating and interactional behavior was found. However, high EE-critical relatives, defined by the brief EE method, were more negative in direct interactions than low EE relatives or high EE relatives classified as emotionally overinvolved. Sequential analyses indicated that high EE-critical relatives showed extreme negative escalation patterns. Patients' reactions to high EE-critical relatives were characterized by self-justification and negative nonverbal behavior. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Expressed emotion and behavior therapy outcome: A prospective study with obsessive–compulsive and agoraphobic outpatients.

The relationship of expressed emotion (EE) to behavior therapy outcome for obsessive-compulsive disorder (n?=?60) and panic disorder with agoraphobia (n&=?41) was investigated. Relatives' emotional overinvolvement and hostility predicted higher rates of treatment dropout. Higher hostility, as assessed by the Camberwell Family Interview (CFI), was related to poorer outcome for target ratings and for the Social Adjustment Scale; higher perceived criticism was also predictive of worse response on target ratings. In contrast, nonhostile criticism on the CFI was associated with better outcome on the behavioral avoidance test. In general, the relationship of EE to outcome was not moderated by type of relative, diagnosis, amount of contact with the relative, or use of psychotropic medication. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Predicting expressed emotion: A study with families of obsessive–compulsive and agoraphobic outpatients.

The authors used structural equation modeling to examine expressed emotion (EE) in relatives of outpatients with panic disorder with agoraphobia (n?=?42) or obsessive–compulsive disorder (n?=?60). EE was examined as a function of patients' illness and personality and as a function of characteristics of relatives themselves. EE was operationalized in terms of hostility on the Camberwell Family Interview (C. E. Vaughn & J. P. Leff, 1976) and patients' ratings of their relatives' criticism (perceived criticism). Key findings include the identification of a characteristic of the relative (self-reported angry thoughts, feelings, and behaviors) that is directly linked to both hostility toward the patient and to perceived criticism, as well as a direct path between relatives' low rates of observed problem solving and their hostility toward the patient. Patient Pathology predicted perceived criticism but not observer-rated hostility. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Validation of a short version of the Camberwell Family Interview.

Describes the validation of a short version of the Camberwell Family Interview (CFI; J. Leff and C. Vaughan, 1985) for the assessment of expressed emotion (EE) in family members with a schizophrenic relative. The Short CFI produced ratings for the EE dimensions of Criticism, Emotional Overinvolvement, and Warmth that were strongly associated with ratings of the same dimensions on the standard, full-length version of the CFI while requiring about one half of the time to administer and score. Validity of the Short CFI was supported by correlations between ratings on the Short CFI and behavioral observations of relatives during a problem-solving interaction with the ill family member. The results suggest that family EE can be reliably assessed with the Short CFI, thus enabling investigators to assess dimensions of family affect toward an ill relative using a more time efficient but equally valid instrument comparable to the standard-length CFI. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Expressed emotion and depression: Interactions between patients and high- versus low-expressed-emotion spouses.

Investigated the behavior of 30 clinically depressed (Research Diagnostic Criteria) patients (mean age 46.1 yrs) and their spouses (mean age 46.6 yrs) during a 10-min face-to-face interaction. Spouses were classified according to high or low levels of expressed emotion (EE) based on the Camberwell Family Interview, and couples were then videotaped discussing low-conflict issues on which they held different views. Findings indicate that, compared with low-EE spouses, high-EE spouses were more negative and less positive toward their depressed partners, both verbally and nonverbally. Specifically, they made more critical remarks, disagreed with patients more frequently, and were less likely to accept what their depressed partner said to them. Patients interacting with high-EE spouses, however, were not significantly more negative, either verbally or nonverbally, than patients interacting with low-EE spouses. Instead, high levels of spouses' EE were associated with low frequencies of self-disclosure and high levels of neutral nonverbal behavior in patients. (28 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Alternative measures of expressed emotion: A methodological and cautionary note.

Undergraduate raters listened to Camberwell Family Interviews that had been conducted with the spouses of depressed patients and then rated each relative with a rating-scale assessment of expressed emotion (EE). Students' ratings of relatives' criticism, hostility, emotional overinvolvement, and warmth were significantly correlated with trained raters' EE assessments obtained in the conventional manner. Despite this correspondence, further analyses revealed that undergraduates' assessments of relatives did not predict 9-mo relapse rates in patients. These results highlight the importance of establishing both the concurrent and predictive validity of any alternative measure of EE. They also emphasize the dangers of assuming that significant correlates of EE are necessarily significant predictors of relapse. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

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

Examined social skills and social perception of 48 schizophrenia/schizoaffective disorder patients (aged 18–55 yrs) in response to negative affect as a function of family expressed emotion (EE). Ss participated in a role-play test, a social perception test, and a problem-solving discussion with a family member and were assessed on several measures of symptomatology. EE of family members was evaluated with the Camberwell Family Interview. On the role-play test, Ss with less critical relatives became more assertive in response to increased negative affect from a confederate portraying either a family member or friend, but Ss with highly critical relatives did not. Ss with highly critical relatives were also less assertive when confronted with negative affect from a confederate portraying a family member rather than a friend. The behaviors of both relatives and Ss during a family problem-solving interaction were related to the EE dimensions of criticism, emotional overinvolvement, and warmth. Patient gender was also related to family problem solving but was independent of EE. S's ratings of affect on a videotaped social perception task were not related to family EE, and there were few differences in psychopathology between Ss with high and low EE relatives.… (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Fibroblast growth factor-2 and -9 regulate proliferation and production of matrix metalloproteinases in human gliomas

BACKGROUND: Although high expressed emotion (EE) has been found to be an important predictor of poor prognosis in a wide range of conditions such as schizophrenia, anorexia and depression no complete explanation exists for individual differences in EE responses. The aim of this paper is to investigate the role of intimacy in determining the level of EE in carers of people with dementia. METHODS: Ninety-nine carers of people with dementia who presented to Old Age Psychiatry Services in South and Central Manchester completed questionnaires to ascertain past and current levels of intimacy. Camberwell Family Interviews (CFIs) were carried out to ascertain levels of EE. RESULTS: Current intimacy was found to be strongly related to EE such that low current intimacy was associated with high EE and there was a significant difference between high and low intimacy groups on measures of criticism and hostility, though not warmth. CONCLUSIONS: The association found between intimacy and EE indicates that high EE may be a characteristic of low intimacy relationships between the carer and the cared-for-person. Since the assessment of EE is time intensive, perhaps a measure of intimacy will provide a short-hand screen for identifying critical and hostile caring environments.     

The structure of expressed emotion: A three-construct representation.

Confirmatory factor analysis was used to explore a 3-factor model of expressed emotion (Criticism, Emotional Overinvolvement, and Positivity) in a sample of 104 outpatients with agoraphobia or obsessive-compulsive disorder and 104 relatives of these patients. Multiple methods of measurement included the Camberwell Family Interview, observation of verbal and nonverbal behaviors during patient–relative problem-solving interactions, and ratings of relatives' behavior made by patients and by relatives. The convergent validity of the 3 individual constructs was demonstrated through single-factor models fitted to Criticism, Positivity, and Emotional Overinvolvement measures. A 3-factor model was then estimated and determined to provide adequate fit to the data, thus demonstrating the distinctiveness of the constructs. Criticism and Positivity were strongly and negatively correlated, whereas Emotional Overinvolvement bore little relationship to the other 2 factors. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Observed emotional involvement and overinvolvement in families of patients with bipolar disorder.

Many studies have examined the construct validity of the criticism component of expressed emotion, but little work has been done on clarifying the emotional overinvolvement (EOI) construct. In a sample of 115 recently episodic patients with bipolar disorder, the authors of the present study examined the construct validity of an observational coding system for both appropriate and inappropriate emotional involvement that permitted separate ratings for relatives' intrusiveness, self-sacrificing behaviors, and distress related to the patient's well-being. Findings support the measure's reliability and convergent validity and are moderately supportive of the measure's discriminant validity. Results also suggest that Camberwell Family Interview (C. E. Vaughn & J. P. Leff, 1976) EOI ratings do not discriminate among the different dimensions of the emotional involvement construct (or their appropriateness or inappropriateness) as revealed in laboratory-based interactions. The findings suggest that clinicians working with such families might consider differentiating among the various ways in which family members are involved with the patient and helping them learn to judge under what circumstances such involvement is appropriate and inappropriate. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Schizophrenia outpatients' perceptions of their parents: Is expressed emotion a factor?

The factors that mediate the association between expressed emotion (EE) and relapse in schizophrenia patients are still unknown. Many researchers hypothesize that interactions with high-EE individuals are stressful for patients, leaving them vulnerable to relapse. It would be useful to investigate whether patients perceive interactions with high-EE parents as stressful. In this study, associations were examined between levels of EE in parents and the types of personal memories patients had about these parents. EE ratings were obtained for both parents of 27 schizophrenia outpatients, and patients were asked to describe "happy, nonstressful" memories and "unhappy, stressful" memories during 2 interviews. Patients recounted fewer nonstressful memories and more stressful memories about high- versus low-EE parents. Implications of these results are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Expressed emotion, adaptation, and patient survival among couples coping with chronic heart failure.

Previous research (J. C. Coyne et al., 2001) that showed that marital functioning predicted mortality among patients with chronic heart failure (CHF) led to an examination of whether expressed emotion (EE) captured negative marital influences on patient survival. The authors assessed EE using 5-min speech samples obtained from patients (137 men and 47 women) and their spouses. Prevalence of EE was low, and patient and spouse EE were unrelated. Spouse EE was not associated with survival, after the authors controlled for severity of illness. Among patient EE variables, high EE status predicted survival, but in the opposite direction of what was anticipated. Overall, relations between EE and self-report measures of adaptation were weak and inconsistent. Despite the strength of findings concerning EE and psychiatric outcomes, EE does not show promise in predicting adaptation to CHF, and researchers and clinicians should instead seek to identify positive marital factors that may promote patient survival. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Expression of a functional tagged human thyrotropin receptor in HeLa cells using recombinant vaccinia virus

The aim of the present study was to assess the prognostic relevance of relatives' interactive behaviour towards the patient, as covered by the Münster Family Interview (MFI), to the further course of the schizophrenic illness. The MFI is a family interview (of the whole family, including the patient) designed to record the emotional family atmosphere based on the concept of expressed emotion (EE). The ratings take place directly after the interview on five scales (criticism, hostility, overinvolvement, resignation and warmth), the resignation scale being added to the 'classic' EE scales. Ninety-nine families of outpatients diagnosed with schizophrenia according to the DSM-III were examined with the MFI during a home visit. The patients were seen 1 and 2 years after the first examination. The target criteria selected for the prognostic significance of the interaction measurements were: rehospitalisation within 2 years; extent of symptoms after 1 year, and psychosocial skills after 1 year. The significance of the interaction dimensions was verified in regression models. The control variable used in the regression models was the Strauss-Carpenter scale. Regression models were produced for the total group and for a subgroup of moderately ill patients. All target criteria yielded serviceable prediction models. The most important variable for prediction was the control variable, the Strauss-Carpenter scale. However the interaction variables made additional contributions to the prognosis, especially in the subgroup of moderately ill patients. The best MFI scale for all the outcome criteria was resignation; criticism predicted only the symptomatology, and emotional overinvolvement the level of social functioning after 1 year. In conclusion, practical work with families of schizophrenic patients should emphasise the protective function of relatives towards patients more strongly.     

Behavioral correlates of maternal expressed emotion in interaction tasks.

Family expressed emotion (EE), a measure of emotional overinvolvement (EOI) and criticism (CRIT), is predictive of relapses and poor treatment outcomes among adults experiencing a range of psychopathology and may predict outcomes among youth with mood disorders. Although it is typically measured by an individual interview with a family member, EE is thought to index family processes and, therefore, should be reflected in family interactional behavior. We examined the association between maternal EE and interactional behavior in a sample of mothers and their 8–12-year-old children. Mother–child dyads participated in three video-recorded interaction tasks—two problem-solving tasks and one planning-fun-activity task. Maternal EE was measured by the Five Minute Speech Sample, and mothers were classified as CRIT, EOI, or low EE. Maternal interactional behavior was coded using the Living in Family Environments coding system. Repeated measures analyses of variance were used to test the hypothesis that both maternal EE and the type of task would predict maternal interactional behavior. On average, maternal critical behavior increased from the first to the second problem-solving task and decreased during the planning-fun-activity task. Mothers high in CRIT showed greater relative frequencies of critical behavior as compared to mothers high in EOI or mothers low in EE. The results suggest that maternal CRIT, as assessed by the Five Minute Speech Sample, is significantly associated with observed maternal critical behavior. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Psychoeducation and expressed emotion in bipolar disorder: preliminary findings

A multifamily psychoeducational intervention was carried out in patients with bipolar disorder. The study explored (1) the effects of the intervention on the level of expressed emotion (EE) of key relatives; (2) the validity of EE defined by a 5-min speech sample as a predictor of relapse; and (3) the evaluations of the intervention program by patients and key relatives. Four key relatives in the treatment group, compared with none in a waiting list control group, changed from high to low EE levels. The change was clinically but not statistically significant, perhaps because of the small sample size. Patients whose key relatives had low EE levels had a significantly lower number of relapses and hospital admissions compared with those whose key relatives had high EE levels. The psychoeducational program was well received by all participants, and there were no dropouts.     

Predictors of relapse in unipolar depressives: Expressed emotion, marital distress, and perceived criticism.

The predictive validity of expressed emotion (EE) and two conceptually related but more easily measured alternatives—marital distress, and patients' perceptions of criticism from spouses—were examined in a sample of hospitalized unipolar depressives. All three psychosocial variables were significantly associated with 9-month relapse rates. Expressed emotion and marital distress predicted the same proportion of variance in patients' outcomes. The single best predictor of relapse, however, was a patient's response to the question "How critical is your spouse of you?" Patients who relapsed rated their spouses as significantly more critical than did patients who remained well. Alone, the perceived criticism variable accounted for more of the variance in relapse rates than that explained by EE and marital distress combined. The results suggest that asking depressed patients how critical they believe their relatives are may facilitate the identification of individuals at high risk for relapse subsequent to hospital discharge. (PsycINFO Database Record (c) 2010 APA, all rights reserved)