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Influence of Carer Expressed Emotion and Affect on Relapse in Non BRITISH JOURNAL OF PSYCHIATRY (2006), 188, 173^179 Influence of carer expressed emotion and affect participating patients, and were conducted before randomisation into the trial. on relapse in non-affective psychosis The trial was based in four National Health Service (NHS) trusts in London and East Anglia in the UK. Within each of E. KUIPERS, P. BEBBINGTON, G. DUNN, D. FOWLER, D. FREEMAN, these trusts, recruitmentwas from speci- P. WATSON, A. HARDY and P. GARETYGARE T Y fied in-patient and out-patientout-patient teams which agreed that all patients who met the eligibility criteria would be asked to participate in the trial. These services were canvassed at least fortnightly for patients with psychosis who were relapsing. Patients Background High expressed emotion High expressed emotion in carers predicts who fulfilled the eligibility criteria were in carers predicts relapse in psychosis, but an increased relapse rate in schizophrenia asked to give their informed consent. (Bebbington & Kuipers, 1994; Butzlaff & Patients with carers who were in contact it is not known why this is so.In our Hooley, 1998). This finding led to the de- (including telephone contact) with them cognitive model of psychosis, we velopment of family interventions, which for at least 10 h a week were also asked postulated thatthe effectis mediated were recently endorsed by the National to give their consent to be contacted. These through affective changes. Institute for Clinical Excellence (NICE) carers were then asked for their consent to guidelines on schizophrenia (National enter the trial. Patients were recruited at Aims Toinvestigate the relationships Institute for Clinical Excellence, 2003). the time of a re-emergence of positive between carer expressed emotion, However, it is not known how critical, symptoms, either from a previously patients’symptoms and carer hostile or overinvolved family relationships recovered state or from a state of persistent lead to the re-emergence of psychosis. Our symptoms. For patients with persistent characteristics during a recent relapse of cognitive model of psychosis (Garety et aletal,, symptoms, a significant exacerbation in psychosis.psychosis. 2001) posits that family environments positive symptoms, typically leading to achieve this via affect, and that patients hospital admission, was required. The MethodMethod Atotal of 86 patients and living with carers who show high expressed inclusion criteria were as follows: current carers were investigatedinvestigatedin in a cross- emotion would have higher levels of diagnosis of non-affective psychosis sectional design. anxiety and depression and lower self- (schizophrenia, schizoaffective psychosis, esteem, but not more symptoms of delusional disorder; ICD–10 F20; World ResultsResults Patients whose carers showed psychosis.psychosis.PreviousPrevious studies have shown that Health Organization, 1992); age 18–65 high expressed emotion had significantly high expressed emotion is ‘not an artefact years; a second or subsequent episode higherlevels of anxiety and depression, of patient morbidity’ (Leff & Vaughn, starting not more than 3 months before 1985: p. 105). As in earlier studies the patient consented to enter the trial; but not more psychotic symptoms or (Barrowclough & Hooley, 2003; Raune etet and a rating of at least 4 (moderate lower self-esteem.Linear regression alal, 2004), we also predicted that carers severity) on at least one positive psychotic showed thatcarers’critical comments who show high expressed emotion would symptom of the Positive and Negative predicted anxietyin patients.Critical have higher levels of ‘burden’, stress, Syndrome Scale (PANSS; Kay, 1991) at depression and avoidant coping style, and the first time of meeting. comments were related to low carer self- lower self-esteem. A total of 86 patients and their carers esteem and avoidantcoping strategies. who had consented to take part in the Low carer self-esteem was also related to PRP trial were included in this study. carer depression, stress and carer METHOD ‘burden’, and to low patient self-esteem. DesignDesign Participants This was a cross-sectional study. The data The study sample consisted of participants Conclusions Our hypothesis was were obtained by trained assessors during recruited for the Psychological Prevention partiallysupported.Carercriticismwas the baseline phase of the randomised of Relapse in Psychosis (PRP) Trial associated with patient anxiety,low carer controlled trial, before allocation. (ISRCTN83557988) and their immediate self-esteem and poor carer coping carers. The PRP is a UK multicentre strategies.Familyinterventions should randomised controlled trial of cognitive– Carer measures focus ononimproving improving these after a relapse of behavioural therapy and family inter- Camberwell Family Interview (CFI; Vaughn & vention for psychosis, designed to test Leff, 1976)1976)Leff, . This is a semi-structured ques- symptoms of psychosis. hypotheses about outcome and about the tionnaire that assesses how well carers get Declaration of interest None.None. psychological processes associated with on with the person who has had a recent psychosis for both carers and participants. episode of psychosis. It covers family re- Funding detailed in Acknowledgements. Studies of psychological processes linked lationships, arguments, time spent together, with psychosis were incorporated into symptoms and role functioning. With the the baseline assessment of carers and carer’s consent this interview is recorded 173173 Downloaded from https://www.cambridge.org/core. 01 Oct 2021 at 03:44:05, subject to the Cambridge Core terms of use. KUIPERS ETE T AL on audiotape, and it is subsequently rated inventory that assesses different coping variables (anxiety, depression, self-esteem for expressed emotion. Ratings are based styles (on a scale where 1¼never, 2never,2¼rarely,rarely, and overall symptoms of psychosis). not only on content of speech but also on arely, 3arely,3¼sometimes and 4¼a lot). The total We next related the components of prosodic variables such as pitch, speed score for each scale is obtained by adding expressed emotion (emotional over- and tone. Five scales are rated: critical the items together. The present study used involvement, hostility, critical comments, comments (frequency count); hostility two questions per scale from the short form warmth and positive remarks) to patients’ (score of 0, 1 or 2); warmth (0–5); emo- of the measure (Carver & Scheier, 1994). symptoms using Pearson’s correlations, tional overinvolvement (0–5); and positive As in a previous study by Raune et aletal followed by multiple linear regression to remarks (frequency count). More than six (2004), we used an avoidant coping sub- control for potential confounding effects. critical comments, any hostility, or a rating scale consisting of 8 items (2 items Finally, we looked at the correlations of 3 or higher for emotional overinvolve- from each of the following: behavioural between carer expressed emotion variables ment categorise a carer as showing high disengagement, mental disengagement, and carer characteristics. expressed emotion. Taped interviews were alcohol/drug use and denial). rated by assessors previously trained by Dr Christine Vaughn to give reliable ratings Patient measures RESULTSRESULTS of expressed emotion. High correlations or phi coefficients were obtained for all ex- PANSS (Kay, 1991). This is a 30-item instru- Patient and carer characteristics pressed emotion scales: 440.76 for critical ment (rated on a scale from 1 to 7) for Around half of the carers were the parents comments, hostility, emotional over- the assessment of phenomena associated of patients, and three-quarters of the involvement, warmth, positive remarks with schizophrenia. Symptoms during the remainder were spouses or partners and overall expressed emotion category. past 72 h are rated, and higher scores indi- (Tables 1 and 2). The mean age of carers cate more severe symptoms. The positive was consequently higher than that of symptoms sub-scale and negative symp- Experience of Caregiving Inventory (ECI; patients (carer mean age 52.9 years, range toms sub-scale each consist of 7 items, Szmukler et al, 1996). This is a 66-item 26–86 years; participant mean age 36.3 and there is also a general pathology sub- instrument that assesses the subjective years, range 18–46 years). Patients were scale consisting of 16 items. experience of caregiving in eight areas defined by not being in their initial episode, (difficult behaviour, negative symptoms, and the mean duration of illness was 11.2 stigma, problems with services, effects on Self-Esteem Scale (Rosenberg, 1965). (see.(see years (range 551 year to 44 years). the family, need to provide back-up, depen- above).above). In total, 72% of the patients were male, dency and loss), together with two areas of and 84% were White. The relatively small positive experiences of caring (positive BeckDepressionInventory^II(BDI^II;Becketal,BeckDepression Inventory^II(BDI^II;Becketal, proportion of patients from a Black ethnic personal experiences and positive aspects 1996)1996). This established instrument con- background (7%) may be accounted for of the relationship). The questionnaire sists of 21 items, each of which is by the low overall proportion of patients measures how often carers have thought measured on a scale ranging from 0 to 3. with carers in the inner-city areas of the about each issue during the past month The total BDI–II score thus ranges from 0 study locations.
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