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THE UNIVERSITY of HULL the Effects of Expressed Emotion In THE UNIVERSITY OF HULL The effects of Expressed Emotion in adjustment to Long Term Health Conditions and its role in Post Stroke Depression Being a Thesis submitted for the Degree of Doctor of Clinical Psychology In the University of Hull by Naheed Rashid, BSc. (Hons) Psychology with Sociology, PG.Dip Psychology June 2011 1 Acknowledgements This research is dedicated to two special people who have forever been an inspiration and strength to me; my dear Dad who’s humility, optimism and love will never fade and who I wish with all my heart was here with me now. And to my courageous Mum, who understands only too well the challenges of life after a stroke, yet has always kept me positive and focused throughout my research. I wish to thank my family, Abbas, Elaine, Tash and Harpreet, for their continuous support, both emotionally and financially. Without your endless help (loans and laughter!) I would not have been able to complete this course. A special thank you to the ‘sisterhood’; we walked together and have finally made it to the end. And to Snoozy for always making me smile. I would like to express my gratitude to Dr Chris Clarke and Dr Miles Rogish for their valuable guidance, encouragement and patience throughout the research process; and Dr Eric Gardiner for his friendship, expertise and countless statistical support. Also, thank you to all the staff in the stroke units, for their commitment in taking on so much more work to help in recruitment and for their countless e-mails of reassurance. Finally, I am indebted to all the stroke survivors and partners who gave up their time and welcomed me into their homes, sharing such heartfelt and emotive experiences with me. Thank you for making this research possible. 2 Overview This research portfolio is divided into three parts: Part one is a systematic literature review of the literature titled ‘Expressed Emotion (EE) in long term health conditions including those with a neurological basis’. A great deal of research has been carried out looking at the role of EE in psychiatric conditions where EE is now seen as a well established strong predictor of relapse in schizophrenia. More recently, research has turned its focus onto the effects of EE within the domain of chronic health conditions, however, whether this maintains the same significance as shown in psychiatric illnesses remains unclear. This review examines the concept of EE in relation to adjustment, course of illness and functional outcomes in long term health conditions. Broadly it explores the individual components of EE (criticism, emotional over-involvement, hostility, warmth and positive remarks) to identify which have been most associated with outcome. Furthermore, this review has also focused upon how EE has been operationalized and measured in to relation long term health conditions. Clinical and research implications are discussed further in this review. Part two is an empirical research study titled ‘Post stroke depression and expressed emotion’. The causes of PSD remain controversial, particularly regarding the location 3 of lesion that could be linked to depression. What remains clear, however, is that depression after a stroke injury is commonly experienced and has been evidenced as one of the key factors influencing adjustment and rehabilitation outcomes. Given the potential of the impact of EE in long term health conditions, particularly on psychological distress, understanding the causes of PSD in terms of how organic and psycho-social factors might relate to each other is vital for recovery. A cross-sectional design was used to investigate the extent to which EE might interact with lesion laterality to determine levels of post stroke depression (PSD) in stroke survivors. It was hypothesised that stroke survivors with a left lesion stroke injury living in a high EE climate would experience higher levels of PSD compared to those with a right lesion stroke injury living in a low EE climate. Secondary aims of this research explored the relationship between lesion laterality and levels of PSD; and levels of EE and PSD. Additional exploratory research was also carried out to examine the extent to which stroke survivors’ perceptions of EE may interact with lesion laterality to determine levels of PSD. Clinical implications and scope for further research are discussed further. Part three contains the appendices which provide further information in relation to the systematic literature review, empirical paper and a reflective statement of the process on this research. 4 Table of Contents Part One: Systematic Literature Review............................................................ 10 Abstract................................................................................................. 12 Introduction........................................................................................... 13 Method.................................................................................................. 18 Search strategy........................................................................................ 18 Search terms............................................................................................ 18 Search limits............................................................................................ 20 Inclusion criteria...................................................................................... 20 Exclusion criteria..................................................................................... 21 Selection process..................................................................................... 22 Assessment of methodological quality of studies................................... 23 Review Findings...................................................................................... 25 Depression and anxiety........................................................................... 31 Course of illness....................................................................................... 34 Functional outcomes and adjustment..................................................... 38 Individual components of EE most associated with adjustment to illness....................................................................................................... 41 Measures applied to assess expressed emotion (EE)............................. 47 Construct of EE in relation to long term illness...................................... 48 Discussion.............................................................................................. 49 Key findings and methodological considerations................................... 50 Other key methodological limitations in the studies accepted for review..................................................................................................... 56 Limitations of the present review.......................................................... 58 Clinical implications............................................................................... 59 Conclusions and future research........................................................... 60 References............................................................................................ 63 Part Two: Empirical Paper................................................................................ 74 Abstract................................................................................................. 76 Introduction........................................................................................... 77 5 Method.................................................................................................. 83 Design..................................................................................................... 83 Participants............................................................................................. 83 Inclusion and exclusion criteria for stroke survivors.............................. 84 Inclusion criteria for partners or spousal carers.................................... 85 Description of sample............................................................................. 85 Procedure.............................................................................................. 86 Measures................................................................................................ 90 Nottingham Extended Activities of Daily Living Scale (EADL)................ 90 Post Stroke Depression Rating Scale (PSDRS)........................................ 91 Level of Expressed Emotion Questionnaire (LEE).................................. 91 Statistical Analysis..................................................................................... 92 Results................................................................................................... 94 Descriptive statistics............................................................................... 94 Scores for EADL, PSDRS and LEE............................................................. 97 Between group differences in measures................................................ 98 Stroke survivor and spouse / partner differences in LEE scores............ 99 Main research question.......................................................................... 100 Secondary research questions................................................................ 101 Exploratory research question................................................................ 102 Model checking......................................................................................
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