Expressed emotion and social function

Psychiatry Research 72 Ž1997. 33]39

Expressed emotion and social function Shimpei Inoue a,U , Shuichi Tanakab , Shinji Shimoderaa , Yoshio Mino c a

Department of Neuropsychiatry, Kochi Medical School, Kohasu, Oko-cho, Nankoku, Kochi, 783 Japan b Watarigawa Hospital, 2278-1, Gudo, Nakamura, Kochi, 787 Japan c Department of Hygiene and Pre®enti®e Medicine, Okayama Uni®ersity Medical School, 2-5-1, Shikata-cho, Okayama, 700 Japan Received 19 September 1996; revised 18 June 1997; accepted 8 July 1997

Abstract We examined whether expressed emotion ŽEE. influenced the social functioning of schizophrenia. Twenty-nine subjects meeting the diagnostic criteria of ICD-9 or DSM-III-R participated in the study. The Camberwell Family Interview was conducted to evaluate EE, and subjects were divided into high EE and low EE groups. The subjects had been followed up for 9 months and their social functioning was compared between the two groups as assessed with the Katz Adjustment Scales. In the high EE group, levels of both performance of socially-expected activities and free-time activities slightly declined at follow-up. In contrast, those in the low EE group improved and the score increase in the level of performance of socially-expected activities was significant Ž P- 0.05.. We confirmed the relationship of families’ EE status with social functioning in schizophrenia. Q 1997 Elsevier Science Ireland Ltd. Keywords: Schizophrenia; Family; Relapse

1. Introduction The expressed emotion ŽEE. style of the relatives of schizophrenic patients has been found to

U

Corresponding author. Tel.: q81 888 802357; fax: q81 888 802360; e-mail: [email protected]

be a good predictor of relapse ŽBrown et al., 1972; Leff et al., 1987; Tanaka et al., 1995.. While there is still controversy regarding the causative role of EE on relapse in schizophrenia, there is a relation between EE and the exacerbation of symptoms. Although the majority of investigations have focused on symptomatology, studies on the relationship between EE and social function are quite

0165-1781r97r$17.00 Q 1997 Elsevier Science Ireland Ltd. All rights reserved. PII S0165-1781Ž97. 00080-2

34

S. Inoue et al. r Psychiatry Research 72 (1997) 33]39

few. Although disturbance of social function is believed to be related to psychopathology}negative symptoms, for example ŽBellack et al., 1990. }some reports have suggested no such correlation between psychopathology and social skills ŽEllsworth et al., 1968; Engelhardt and Rosen, 1976.. Additionally, some patients from high EE families were found to have poor premorbid psychosocial functioning and greater residual symptomatology ŽMiklowitz and Goldstein, 1983., which further suggests an association of high EE with impaired functioning after the onset of the illness. If a family’s EE exerts a strong effect on the social function of schizophrenic relatives, this could provide us with an important tool for family intervention. Studies focusing on the relationship of EE with social function have begun only recently. Otsuka et al. Ž1994. showed that patients from high EE households had poor social skills, while King and Dixon Ž1995. found that some aspects of high EE were associated with better social adjustment. Thus, it is still controversial whether or not there is a uniform association between a high degree of EE and social adjustment. The aim of this study was to examine the relationship of families’ EE status with social adjustment in persons with schizophrenia. 2. Methods As we have previously reported on the relationship of families’ EE status with relapse ŽTanaka et al., 1995; Mino et al., 1997., we briefly repeat the methods here. Subjects were selected from patients with schizophrenia who were consecutively admitted to the Department of Neuropsychiatry, Kochi Medical School and the Tosa Hospital, an affiliated teaching hospital of the school in Kochi prefecture, Japan. Subjects were included in the study if they were between 15 and 65 years old, were diagnosed as suffering from schizophrenia according to ICD-9 andror DSMIII-R criteria, had lived with their families at least 3 months prior to admission, and were expected to return to their families after discharge. The Camberwell Family Interview ŽCFI. was administered to the key relatives within 2 weeks

of admission. All interviews were audio-taped, and one of the authors who is a certified EE rater ŽY.M.. evaluated the EE status of each family. If at least one family member made six or more critical comments ŽCC., andror was rated one or more on the hostility scale ŽGeneralization andror Rejection., andror was rated three or more on the Emotional Overinvolvement ŽEOI. scale, the family was classified as high in EE, while those who did not fit these criteria were considered to be a low EE family. Demographic data of the subjects including age, sex, duration of illness, and number of previous admissions were obtained at admission. The number of initial subjects who satisfied these criteria was 73. Among these, the families of 11 patients refused to be interviewed and, in another 10 cases, the interview was impossible because of problems related to families’ mental illness. There were no significant differences in age, sex, duration of illness, or number of previous admissions between the included patients and those that were not ŽTanaka et al., 1995.. Of the remaining 52 cases, 39 lived with parentŽs., nine with a spouse, three with parents and spouse, and one with a sibling. There were 34 fathers Ž46]78 years old., 39 mothers Ž39]78 years old., five husbands Ž39]71 years old. and seven wives Ž31]69 years old.. Nearly all of the families were in the middle ŽIII. or lower-middle ŽIV. class, according to the Hollingshead and Redlich Index of Social Position. The research design was a cohort study, and both high EE and low EE groups were followed up for 9 months after discharge. Social functioning was compared between the two groups as assessed with the Katz Adjustment Scales ŽKAS; Katz and Lyerly, 1963., which include five types of measures. We used two in order to assess the social functioning of patients: Level of Performance of Socially-expected Activities ŽLPSA. and Level of Free-time Activities ŽLFA.. The former contains 16 items that cover family and social responsibilities, social activities, self-care, home adjustment, and community activities, while the latter contains 22 items that cover hobbies, social and community activities and self-improvement activities. The other three types of scale measures

S. Inoue et al. r Psychiatry Research 72 (1997) 33]39

were omitted in this study because one rates symptomatology and the other two rate families’ degree of expectation and satisfaction. Because of cultural differences, three of the original items were freely translated. ‘goes to church’ was translated into ‘participates in some religious or volunteer activities’, ‘plays cards or other table games’ into ‘plays mah-jong or other indoor games’, and ‘takes courses at home’ into ‘attends community courses’. The response format, rating scales and the calculation of total scores were the same as in the original ŽKatz and Lyerly, 1963.. We mailed a questionnaire twice to one of the family members who appeared to be most familiar with the patient’s daily life. All were CFI interviewees. All but one reply was from the same family member to whom we sent the mail. They were instructed to fill out the form under the same instructions as the original. These instructions were prepared in written form. Although the original KAS was designed as an interview, we mailed the questionnaire because we thought that it would be easy for relatives to understand and follow the instructions and that results would lend themselves to analysis. We requested evaluation of the patients’ social functioning, observing it for the period of 3 weeks after discharge, and 9 months after discharge. All patients received out-patient care, mainly in the form of pharmacotherapy. Regular pharmacotherapy was defined as a drug prescription period lasting more than 75% of the total 9-month follow-up period with the duration of non-prescription periods not exceeding 4 consecutive weeks. We later checked with the patient’s psychiatrist, who reported our assessment to be reasonable. Patients’ symptoms were evaluated using a Japanese version of the Brief Psychiatric Rating Scale ŽBPRS; Overall and Gorham, 1962.. The assessment was administered 9 months after discharge or at any point at which the patient’s psychiatrist suspected a relapse. We defined relapse as a 3-point or greater increase on any positive symptom on the BPRS compared to baseline scores at the time of discharge ŽGottschalk et al., 1988; Tanaka et al., 1995.. In order to control for any potentially confounding factors, multiple regression analysis was performed using KAS

35

Table 1 Comparison between completer and drop-out groups

Number Malerfemale Mean age Duration of illness Prior admissions Discharge BPRS score EE status Žhighrlow.

Completer

Drop-out

29 22r7 37.5" 13.5 14.0" 10.9 5.1" 4.9 28.7" 9.0 18r11

23 15r8 32.9" 12.1 9.0" 8.4 4.8" 4.1 30.6" 10.8 10r13

Results are mean " S.D.

scores at 9 months after discharge as the criterion variable and the EE status, age, sex, duration of illness, number of previous admissions, drug compliance, and KAS scores at the time of discharge as predictor variables. Statistical analysis was conducted with SPSS-X. 3. Results Twenty-nine patients and their families were successfully followed up for 9 months. We sent the KAS to 52 families twice by mail. Of these, 13 families responded only once and 10 families did not respond to either mailing. Comparison between the completer and drop-out groups showed no differences in characteristics including the severity of symptoms at discharge ŽTable 1.. Of the 29 cases in which KAS data were available, 11 patients came from high EE and 18 from low EE households. A comparison of the characteristics between these two groups and the EE components of the high EE group are shown in Table 2. None of the items significantly differed between the two groups. Although the average interval between admissions seemed to be different between the two groups, it did not reach the significant level. Table 3 shows the changes of LPSA and LFA scores during the 9-month follow-up for both the high EE and low EE households. The baseline scores at discharge were very close between the two groups for both the LPSA Žtwo-sample t-test: t s 0.04, df s 27, Ps 0.97. and LFA Žtwo-sample t-test: t s 0.41, df s 27, Ps 0.68., which indicates

S. Inoue et al. r Psychiatry Research 72 (1997) 33]39

36 Table 2 Patient characteristics

Number Malerfemale Mean age Duration of illness Prior admissions Discharge BPRS scores Total Positive scales Negative scales Depressive scales EE component in high EE families CC CC and hostility EOI

High EE

Low EE

Total

11 7r4 34.4" 12.7 11.0" 8.4 6.0" 7.3

18 15r3 39.4" 13.9 15.9" 12.0 4.6" 2.5

29 22r7 37.5" 13.2 14.0" 10.7 5.1" 4.8

27.2" 5.9 11.3" 2.3 6.7" 4.4 3.5" 2.6

29.7" 10.6 10.9" 4.8 8.7" 4.0 1.8" 2.0

28.7" 8.9 11.0" 3.9 8.0" 4.1 2.9" 2.5

5 3 3

Results are mean " S.D.

homogeneity of the two groups in terms of level of social functioning at discharge. After 9 months, mean LPSA and LFA scores in the high EE group declined slightly; 46% of the patients had score reductions on the LPSA, and 64% did on the LFA. In contrast, mean scores on the two items in the low EE households increased; increases in LPSA scores were significant Ž t s 2.16, df s 17, Ps 0.045.. Only 22% and 39% had score reductions on LPSA and LFA scores, respec-

tively. The two-sample t-test, which compares the differences of the LPSA and LFA of each family household during the 9-month period, however, failed to show significant changes. There has been some controversy about whether social functioning is dependent onpsychopathology. To study this, the KAS scores were compared between relapsers Ž N s 8. and non-relapsers Ž N s 21. ŽTable 4.. KAS scores significantly reduced over the 9 months in relapsers.

Table 3 Relatives KAS ratings KAS subscale Performance EE status High Low

Activities

Discharge

9 months

Difference

25.0" 5.8 25.1" 6.0

24.3" 7.6 28.1" 6.2

y 0.7" 5.5a 3.1" 5.8 c

Paired t-test: a t s 0.41 Ž10 df., Ps 0.69. b t s 1.23 Ž10 df., Ps 0.25. c t s 2.16 Ž17 df., Ps 0.045. d t s 0.90 Ž17 df., Ps 0.38. Two sample t-test: e t s 1.68 Ž27 df. Ps 0.10. f t s 1.62 Ž27 df. Ps 0.12. Results are mean " S.D.

5

e

Discharge

9 months

Difference

30.1" 3.9 29.4" 4.5

27.2" 6.1 30.7" 5.1

y 2.9" 7.5 b 1.3" 5.9 d

5

f

S. Inoue et al. r Psychiatry Research 72 (1997) 33]39

37

Table 4 KAS score vs. relapse status KAS subscale Performance Relapse status Relapsers Non-replasers

Activities

Discharge

9 months

Difference

Discharge

25.1" 3.8 25.0" 6.6

21.1" 3.7 28.8" 6.8

y 4.0" 3.8 a e 3.8" 5.3 c

5

31.0" 3.7 29.1" 4.5

9 months

Difference

24.8" 5.2 31.1" 4.9

y6.3" 5.7 b 2.0" 5.8 d

5

f

Paired t-test; a t s 2.76 Ž7 df., Ps 0.028. t s 2.88 Ž7 df., Ps 0.024. c t s 3.20 Ž20 df., Ps 0.005. d t s 1.51 Ž20 df., Ps 0.15. Two-sample t-test, e t; Ž27 df. Ps 0.001. f t s Ž27 df. Ps 0.003. Results are mean " S.D. b

Reduction of LPSA mean scores was 4.0 Ž t s 2.76, df s 7, Ps 0.028. and that of LFA scores was 5.2 Ž t s 2.88, df s 7, Ps 0.024.. In the non-relapsers, the LPSA mean score increase was 3.8 Ž t s 3.20, df s 20, Ps 0.0045. and the LFA mean score increase was 2.0 Ž t s 1.51, df s 20, Ps 0.15.. Thus, those suffering from relapseexperienced decline in social functioning and those without relapse continued to improve. The two-sample t-test, which compares the differences of the LPSA and LFA of each family household during the 9-month period, also showed significant changes. Acute exacerbation of symptoms could lead to poorer

social functioning. The timing of the 9-month assessment showed that six of eight relapsers were fully recovered, one almost recovered from acute exacerbation, and one acutely ill. This review indicates that social functioning in the relapsers might be slightly influenced by symptoms. In order to control for other confounding factors such as sex, duration of illness, drug compliance, total BPRS score, and baseline level of social functioning, a multiple regression analysis was conducted ŽTable 5.. For the KAS total score, LPSA scores, and LFA scores, the standardized beta values of EE status were y0.35 Ž Ps 0.07.,

Table 5 Multiple regression analysis KAS total Standardized beta EE status Sex Duration of illness Drug compliance Discharge BPRS score Discharge KAS score Discharge performance score Discharge activity score Adjusted R 2

y0.35 0.22 y0.16 0.25 y0.05 0.26 } } 0.19

Level of performance t

P

y1.89 1.14 y0.86 1.38 y0.28 1.47 } }

0.07 0.27 0.40 0.18 0.78 0.15 } }

Standardized beta y0.36 0.35 y0.20 0.19 y0.03 } 0.38 } 0.44

Level of free-time activities

t

P

y2.34 2.05 y1.31 1.26 y0.19 } 2.23 }

0.03 0.052 0.21 0.22 0.85 } 0.04 }

Standardized beta y0.26 0.0008 y0.09 0.25 y0.07 } } 0.11 0.08

t

P

y1.26 0.004 y0.41 1.22 y0.35 } } 0.56

0.22 0.99 0.68 0.24 0.73 } } 0.58

38

S. Inoue et al. r Psychiatry Research 72 (1997) 33]39

y0.36 Ž Ps 0.03., and y0.26 Ž Ps 0.22., respectively; EE status was significantly related to the LPSA scores in analyses controlling for the potential confounding factors. Baseline level of LPSA also correlated significantly to LPSA scores at follow-up Ž b s 0.38, Ps 0.04.. There appears to be a near-significant gender effect for the LPSA: the females acquired higher scores at follow-up in analyses controlling for other confounding factors. 4. Discussion The results of this study suggested that EE status and social functioning assessed with the Katz Adjustment Scales in schizophrenic families with high EE family attitudes are related to poorer social functioning in patients. The relationship was especially robust at the level of performance of socially-expected activities. This study has limitations: the reduced sample size due to rather large sample attrition, and potential information bias as a result of using relatives as informants. Although the comparison between completer and drop-out groups showed no differences on demographic and clinical characteristics, the small number of subjects raised the question of whether the sample was representative and weakened the statistical power. The latter may have led to the failure to find significant differences of social functioning between high and low EE groups using the two-sample t-test. We used relatives as informants on social adjustment, and this may have produced a certain bias; highly critical relatives might report patients’ behavior more negatively. As the KAS items were rather specific and deliberately chosen ‘in order to minimize the extent to which the relative’s involvement would interfere with his reporting’, and ‘to avoid placing the relative in the position of judging the patient’ ŽKatz and Lyerly, 1963., bias may have been minimal. Still, scales of expectation and satisfaction in the KAS would have made these points clearer. Our findings replicated those of Otsuka who assessed family expressed emotion by the FiveMinute Speech Sample ŽFMSS; Magana ˜ et al., 1986. and patients’ social functioning with the

KAS. In this study, high EE relatives tended to evaluate their patients’ performance of sociallyexpected activities considerably lower than low EE families. In addition, our results agree with those of Barrowclough and Tarrier Ž1990., who used the CFI to assess family status and the Social Adjustment Scale ŽSAS; Weissman et al., 1978. to assess patients’ social functioning. They showed that patients living with high EE relatives function significantly worse than those living with low EE relatives. The mechanisms that impair patients’ social functioning in high EE households have been hypothesized in two ways. Firstly, as was pointed out by Kuipers Ž1987., emotional overinvolvement may prevent the development of patients’ independent social functioning. Secondly, patients’ work disability may be the cause of criticism in relatives ŽBrown et al., 1972.. These family dynamics seem to be a key point for intervention. The study of King and Dixon Ž1995., who used the CFI and the SAS, demonstrated interesting results. Although there were numerous differences in methodology between their study and ours, and it is difficult simply to compare the results, one of their findings should be mentioned. They found better social adjustment to be associated with greater emotional overinvolvement, especially from mothers. They stated that better social functioning was related to functioning within the family context, and that patients may profit most from an ‘optimal’ level of emotional overinvolvement. The measurement of emotional overinvolvement is greatly influenced by culture ŽMino et al., 1995., and this could lead to a variety of effects on social functioning of an ill member in the family. Our results suggest a causal role for EE on social performance from the result that EE status was significantly related to the social performance, while baseline social performance did not differ between high and low EE status. As there are few reports on the relationship between EE and social functioning, the interpretation of the results of this study requires caution. Cross-sectional studies have limits in the inference of cause and effect.

S. Inoue et al. r Psychiatry Research 72 (1997) 33]39

The results of an intervention study by Barrowclough and Tarrier Ž1990. provide some hints in this context. Showing that family intervention was able to reduce relapse rates and improve social functioning, they discussed that improved level of social functioning might reduce the grounds for criticism and negative attitudes on the part of the relatives. At the same time they wrote that it is impossible to state confidently that this underlay the process of change. It is not a useful question whether high EE causes or results from poor social functioning. There may be some interactive process between relatives’ negative attitudes and patients’ poor social functioning. An intervention study that can provide close observation of the interactive process may give us more fruitful information. Our group is now planning further study in this area. Acknowledgements The authors express their thanks to Dr. Koichiro Suto, Director of Tosa Hospital, and Dr. Shunjiro Suto, Deputy Director of the hospital, who allowed access to patients in their care. References Barrowclough, C., Tarrier, N., 1990. Social functioning in schizophrenic patients: I. The effects of expressed emotion and family intervention. Social Psychiatry and Psychiatric Epidemiology 25, 125]129. Bellack, A.S., Morrison, R.L., Wixted, J.T., Mueser, K.T., 1990. An analysis of social competence in schizophrenia. British Journal of Psychiatry 156, 809]818. Brown, G.W., Birley, J.L.T., Wing, J.K., 1972. Influence of family life on course of schizophrenic disorders: a replication. British Journal of Psychiatry 121, 241]258. Ellsworth, R.B., Foster, L., Childers, B., Arthur, G., Kroeker, D., 1968. Hospital and community adjustment as perceived by psychiatric patients, their families, and staff. Journal of Consulting and Clinical Psychology 32, 1]41. Engelhardt, D.M., Rosen, B., 1976. Implication of drug treatment for the social rehabilitation of schizophrenic patients. Schizophrenia Bulletin 2, 454]462.

39

Gottschalk, L.A., Falloon, I.R.H., Marder, S.R., Lebell, M.B., Gift, T.E., Wynne, L.C., 1988. The prediction of relapse of schizophrenic patients using emotional data obtained from their relatives. Psychiatry Research 25, 261]276. Katz, M.M., Lyerly, S.B., 1963. Methods for measuring adjustment and social behavior in the community: I. Rationale, description, discriminative validity and scale development. Psychological Reports 13, 503]535. King, S., Dixon, M.J., 1995. Expressed emotion, family dynamics and symptom severity in a predictive model of social adjustment for schizophrenic young adults. Schizophrenia Research 14, 121]132. Kuipers, L., 1987. Research in expressed emotion. Social Psychiatry 22, 216]220. Leff, J., Wig, N.N., Ghosh, A., Bedi, H., Menon, D.K., Kuipers, L., Korten, A., Ernberg, G., Day, R., Sartorius, N., Jablensky, A., 1987. Expressed emotion and schizophrenia in North India III. Influence of relatives’ expressed emotion on the course of schizophrenia in Chandigarh. British Journal of Psychiatry 151, 166]173. Magana, ˜ A.B., Goldstein, M.J., Karno, M., Miklowitz, D., Jenkins, J., Falloon, I.R., 1986. A brief method for assessing expressed emotion in relatives of psychiatric patients. Psychiatry Research 17, 203]212. Miklowitz, D., Goldstein, M.J., 1983. Premorbid and symptomatic characteristics of schizophrenics from families with high and low levels of expressed emotion. Journal of Abnormal Psychology 92, 359]367. Mino, Y., Tanaka, S., Inoue, S., Tsuda, T., Babazono, A., Aoyama, H., 1995. Expressed emotion components in families of schizophrenic patients in Japan. International Journal of Mental Health 24, 38]49. Mino, Y., Inoue, S., Tanaka, S., Tsuda, T., 1997. Expressed emotion among families and course of schizophrenia in Japan: a 2-year cohort study. Schizophrenia Research 24, 333]339. Otsuka, T., Nakane, Y., Ohta, Y., 1994. Symptoms and social adjustment of schizophrenic patients as evaluated by family members. Acta Psychiatrica Scandinavica 89, 111]116. Overall, J.E., Gorham, D.P., 1962. The Brief Psychiatric Rating Scale. Psychological Reports 10, 799]812. Tanaka, S., Mino, Y., Inoue, S., 1995. Expressed emotion and the course of schizophrenia in Japan. British Journal of Psychiatry 167, 794]798. Weissman, M.M., Prusoff, B.A., Thompson, W.D., Harding, P.S., Myers, J.K., 1978. Social adjustment by self-report in a community sample and in psychiatric outpatients. Journal of Nervous and Mental Disease 166, 317]326.