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Family Environment in Early Psychosis. in Search of The ADVERTIMENT. Lʼaccés als continguts dʼaquesta tesi queda condicionat a lʼacceptació de les condicions dʼús establertes per la següent llicència Creative Commons: http://cat.creativecommons.org/?page_id=184 ADVERTENCIA. El acceso a los contenidos de esta tesis queda condicionado a la aceptación de las condiciones de uso establecidas por la siguiente licencia Creative Commons: http://es.creativecommons.org/blog/licencias/ WARNING. The access to the contents of this doctoral thesis it is limited to the acceptance of the use conditions set by the following Creative Commons license: https://creativecommons.org/licenses/?lang=en Universitat Autònoma de Barcelona Facultat de Psicologia Departament de Psicologia Clínica i de la Salut Doctorat en Psicologia Clínica i de la Salut Doctoral Thesis Family Environment in Early Psychosis In search of the psychological mechanisms underlying the manifestation of Expressed Emotion in at-risk and onset stages of psychosis by: Lídia Hinojosa Marqués Supervisor: Prof. Neus Vidal Barrantes Bellaterra (Barcelona) September 2018 Universitat Autònoma de Barcelona Facultat de Psicologia Departament de Psicologia Clínica i de la Salut Doctorat en Psicologia Clínica i de la Salut Doctoral Thesis Family Environment in Early Psychosis In search of the psychological mechanisms underlying the manifestation of Expressed Emotion in at-risk and onset stages of psychosis Prof. Neus Vidal Barrantes Lídia Hinojosa Marqués Als meus pares, per un tot immesurable. A tu, Roger, per fer sempre fàcil el que resulta difícil. “Understanding is a two-way street” Eleanor Roosevelt “Normality is a paved road: It’s comfortable to walk, but no flowers grow” Vincent van Gogh Acknowledgments/ Agraïments/Agradecimientos En primer lloc, m’agradaria expressar la meva gratitud a la meva directora de tesi, la professora Neus Vidal Barrantes: Estimada Neus, descobrir-te en les classes del màster de recerca va suposar un punt d’inflexió en la meva trajectòria digne de ser qualificat d’experiència d’insight intel·lectual. Concebre el fenomen psicopatològic sota un prisma dimensional em va obrir una via de coneixement que em va deixar intel·lectualment fascinada. Gràcies per brindar-me la confiança i la oportunitat d’aprofundir en molts interrogants al teu costat i dins del teu grup de recerca. T’agraeixo profundament tots els coneixements i valors científics que m’has transmès durant tots aquests anys, però sobretot gràcies pel teu esperit creatiu i per encomanar-me la teva gran passió per aquest ofici meravellós que és la ciència. Sens dubte, el teu suport i la teva guia han estat crucials durant tot aquest trajecte que hem fet plegades. Sempre gràcies, Neus. Thanks to Prof. Kwapil for your helpful advice and support with the methodological part of this thesis. Gràcies a tots els investigadors/es que formen o han format part del grup Interacció Persona-Ambient en Psicopatologia, tots i cadascun d’ells han contribuït significativament a fer possible la consecució d’aquesta tesi doctoral. Gràcies Sergi, Mercè, Aida, Bea, i especialment gràcies a: Anna, gracias por tu cariño y amistad a lo largo de todos estos años, pero también te agradezco muchísimo tu calidez y sensibilidad que siempre me han aportado mucha calma en los momentos difíciles. Sei speciale amica mia. Manel, has estat un company inestimable en tots els sentits. Treballar amb tu “colze a colze” ha estat un plaer. Gràcies per tantes converses inspiradores sobre clínica, dins i fora de les consultes, però sobretot gràcies per haver estat tan proper, solidari i generós amb mi. Paula, gràcies per oferir-me sempre desinteressadament la teva ajuda i per compartir amb mi tots els teus coneixements metodològics i d’estadística. Amb tu he aprés les qualitats que ha de reunir una bona investigadora, però també les qualitats que ha de tenir algú que treballa dins d’un equip. Gràcies per la teva empatia i qualitat humana. Mi profundo agradecimiento a Tecelli que a pesar de la lejanía y de la diferencia horaria ha estado muy implicada en todo lo que concierne a esta tesis. Tecelli, tu criterio y tu apoyo han sido inestimables para mí. Te lo agradezco mucho, de corazón. Tam, gracias por brindar-me tu ayuda siempre. Tu meticulosidad y criterio científico hacen que el trabajo que pasa por tus manos adquiera un valor significativamente mejor. Raúl, gracias por mostrarte siempre cercano, atento y dispuesto a ayudar. Moltes gràcies a tots els psicòlegs, psiquiatres, treballadors socials i personal administratiu del CSMA de Montjuic, del CSMA de Cal Muns, del CSMIJ i de l’Hospital de dia infanto-juvenil de la Fundació Sanitària Sant Pere Claver (SPC) per facilitar-nos els recursos necessaris per poder realitzar el mostreig de pacients i familiars d’aquest projecte. Compartir aquesta experiència amb vosaltres ha estat molt enriquidora a nivell clínic i personal. Gràcies molt especialment a aquells pacients i familiars que fan possible aquest projecte i que han compartit amb mi les seves experiències més personals. Les seves històries no només es converteixen en dades molt valuoses que contribueixen al coneixement científic sinó que també són lliçons de vida que ens aporten humanitat i desenvolupament personal als qui tenim la sort de dedicar-nos a aquest ofici. Finalment, tinc un deute intens de gratitud envers la meva família i les meves amigues i amics. Mireia i Laura, gràcies per la més bonica i intensa de les històries de convivència que no va quedar tancada a les portes de Còrsega, sinó que es continua repetint de forma paral·lela a les nostres rutines per assegurar-nos un espai mental innocu al que sempre podem tornar. Amigues, aquesta tesi és tan vostra com meva, perquè tot el que neix a Còrsega és de Còrsega. Ramón O., tiempos pasados y pretéritos, queda mucho por compartir para seguir repitiendo “I remember when”. Gracias por tu forma de hacerme notar que estás siempre ahí y por tu sentido del humor, ácido, tan terapéutico para mí. Núria, gràcies per anar sempre més enllà del que és purament visible. La teva intuïció, calidesa i empatia et converteixen en algú imprescindible per mi. Gràcies a les meves amigues i amics d’Alfarràs. La vostra companyia a llarg tota la vida ha suposat un autèntic avantatge en l’ofici de viure. Us estaré eternament agraïda per les vostres mostres de suport durant tots aquest anys de tesi. Sol puc dir-vos que em quedo en un estat de continuar-vos retornant en el dia a dia el que us correspon, que és i ha estat sempre, el millor de mi. Gràcies, amigues i amics de Mataró, m’heu fet sentir que casa vostra es casa meva, en tots els sentits. Quan algú sent que els seus propòsits i preocupacions es comparteixen entre tots, es sent part d’una família i això és el que m’heu transmès vosaltres. Gràcies, Roger. Si algú ha comprès quin és l’esforç que comporta fer una tesi doctoral, aquest ets tu. Gràcies per escoltar-me, cuidar-me i encoratjar-me durant tot aquest procés, però sobretot gràcies per l’harmonia i la pau que m’has transmès. Tot el que fas per mi em corprèn un cop més. T’estimo. I per últim, gràcies als que indiscutiblement han estat l’autèntic vehicle per arribar a totes les meves fites personals: Gràcies, Mama i Papa, Mª Carmen i Francisco. Tot el que fins ara soc parteix d’una base sòlida de valors que m’heu inculcat vosaltres. Gràcies per fer-me sentir estimada, recolzada, segura i capaç d’assolir els meus propòsits, però sobretot gràcies per mesurar la vostra felicitat a través de la meva. Us estimo. Grant information This work was supported by the Spanish Ministerio de Economía y Competitividad (Plan Nacional de I + D PSI2014-54009-R and PSI2017-87512-C2-00), Fundació La Marató de TV3 (091110) and Comissionat per a Universitats i Recerca of the Generalitat de Catalunya (2014SGR1070 and 2017SGR1612). CONTENTS 1. INTRODUCTION………………………………………………………………..15 2. THEORETICAL FRAMEWORK………………………………………………..21 2.1 The Extended Psychosis Phenotype and the Continuum Hypothesis .............................21 2.2 From Chronic Schizophrenia to Early Psychosis: Early detection and Intervention in Psychosis………………………………….…………………………………………24 2.3 Etiological factors in the Emergence of Psychosis……………………..…….………28 2.3.1 Environmental Risk Factors: The Role of Family Environment………............................29 2.3.1.1 Expressed Emotion and Schizophrenia Relapse…………...……...…….……31 2.3.1.2 The Early Development of Expressed Emotion………………............………35 2.3.1.2.1. Expressed Emotion as a reaction to patients’ clinical and functional outcomes……………………………………………………………….....37 2.3.1.2.2. Expressed Emotion as a product of relatives’ attributions about patients’ symptoms………………………………………………………………...38 2.3.1.2.3 The stress and coping model and its relationship to Expressed Emotion………………………………………………………………....39 2.3.1.2.4 Expressed Emotion and family members’ perceived loss: the role of attachment ………………………………………………….......................41 3. AIMS AND OUTLINE OF THIS THESIS……………………….…………...….43 References……………………………………………………………………………….46 4. THEORETICAL INVESTIGATION……………………………………...…….75 SECTION 1: FAMILY ENVIRONMENT RESEARCH IN AT-RISK MENTAL STATE STAGES OF PSYCHOSIS……………………………………………….......76 Chapter 1: Family environmental factors in At-Risk Mental States for Psychosis....................77 Abstract……………………………………………………………………………..78 Introduction……………………………………………………………………........79 Methods…………………………………………………………………………….81 Results………………………………………………………………………...….....82 Discussion…………………………………………………………………………..88 Tables …………………………………….…………………………………….…..95 References………………………………………………………………………....101
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