The Family Questionnaire: Development and validation of a new self-report scale for assessing expressed emotion

Psychiatry Research 109 (2002) 265–279

The Family Questionnaire: Development and validation of a new self-report scale for assessing expressed emotion Georg Wiedemanna,*, Oliver Raykia, Elias Feinsteinb, Kurt Hahlwegc a

¨ ¨ University of Tubingen, Department of Psychiatry and Psychotherapy, Osianderstr. 24, D-72076 Tubingen, Germany b Max Planck Institute of Psychiatry, Department of Psychiatry, Kraepelinstr. 2-10, D-80804 Munich, Germany c Technical University of Braunschweig, Institute of Psychology, Spielmannstr. 12A, D-38106 Braunschweig, Germany Received 14 May 2001; received in revised form 17 January 2002; accepted 27 January 2002

Abstract The level of expressed emotion (EE) as assessed in the Camberwell Family Interview (CFI) has proved to be one of the best predictors of relapse in schizophrenia. The present study describes the development and validation of the Family Questionnaire (FQ), a brief self-report questionnaire measuring the EE status (criticism, emotional overinvolvement) of relatives of patients with schizophrenia. The FQ classifications in the initial sample of relatives (Ns 76) correlated significantly with the ratings in the CFI subcategories ‘criticism’ (78% correct classifications) and ‘emotional overinvolvement’ (71% correct classifications), as well as with the overall CFI EE ratings (74% correct classifications). A validation study in an independent second sample (Ns79) yielded similar results. The overall correct classification rate of 74% remained unchanged. The FQ had better agreement with the CFI on emotional overinvolvement than did other short EE questionnaires. 䊚 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Expressed emotion; Camberwell Family Interview; Emotional overinvolvement; Schizophrenia; Relatives; Family Questionnaire (FQ)

1. Introduction Prediction of the risk of relapse in individuals with psychiatric disorders is of great importance, especially with respect to adequate relapse prevention. The expressed emotion (EE) concept (Leff and Vaughn, 1985), a measure of attitudes and behavioral patterns of relatives towards patients, *Corresponding author. Tel.: q49-7071-298 2297; fax: q49-7071-29 4141. E-mail address: [email protected] (G. Wiedemann).

has been shown to be a good predictor of relapse in patients with various diagnoses, including schizophrenia, eating disorders and mood disorders (Bebbington and Kuipers, 1994; Butzlaff and Hooley, 1998). EE classification of relatives is based mainly on two variables ‘criticism’ (critical comments, CC) and ‘emotional overinvolvement’ (EOI). A third variable, ‘hostility’, is normally associated with high levels of CC. The risk of relapse is three to four-fold greater for inpatients with schizophrenia returning to high-

0165-1781/02/$ - see front matter 䊚 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 1 6 5 - 1 7 8 1 Ž 0 2 . 0 0 0 2 3 - 9

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EE home environments than for those returning to low-EE families within the first year after discharge from the hospital (Kavanagh, 1992). The semi-structured Camberwell Family Interview (CFI, Vaughn and Leff, 1976) is a standardized instrument for rating EE. The interview is conducted with each relative individually and takes approximately 4 h per relative for recording and evaluation, i.e. approximately 8 h per family in the father–mother–patient constellation. Including the approximately 2-week period for rater training, this is a very time-consuming procedure and one that precludes routine clinical use. A number of shorter procedures for assessing EE have therefore been developed. In an overview on the status of EE research, Kavanagh (1992) expressed the view that the development and validation of alternatives to the CFI was one of the primary tasks confronting future research. The existing procedures vary as to whether assessment of the EE status of relatives is based on questioning of patients, relatives, or both, and whether an interview or a questionnaire is used. 1.1. Speech sample procedures In the speech sample procedures, relatives are asked to talk about the patient continuously for 5 to 10 min and the speech sample is then analyzed (Gottschalk and Gleser, 1969). There are three such procedures: the Gottschalk–Gleser procedure (Gottschalk et al., 1988); the Five Minute Speech ˜ et al., 1986); and the 10Sample (FMSS, Magana min ‘short interview’ (Wittgen et al., 1989).

For some of the short questionnaires, the correlations with the CFI classifications of relatives of schizophrenic patients have been relatively low (PBI) or contradictory (PBI, PC), whereas for others they have been somewhat higher (PRS, LEE, FAS). For instance, Kazarian et al. (1990) reported significant correlations between some scales of the LEE and the CFI category CC, although none with the CFI category EOI. For a number of other questionnaires, no correlations of EE ratings with CFI EE classifications have been reported. Therefore, the suitability of these scales for determining EE status cannot yet be evaluated. With the exception of one PBI result (Parker et al., 1989), which has yet to be replicated and was confined to the subgroup of mothers, none of the questionnaire methods achieved high correlations with the CFI EOI classification. Thus, a questionnaire for brief assessment that enables accurate assessment of the EE-relevant categories CC and EOI has yet to be developed. Our objective in developing the Family Questionnaire (FQ) was to achieve this goal. Our intention was to provide a brief measure that is easier to administer and is less time-consuming than the CFI or the FMSS, but nevertheless is at least equivalent to the FMSS in terms of validity. It should also be suitable for repeated administration. There should be no need for any training before it can be used, and the time needed for administration and evaluation should be minimal. 2. Methods

1.2. Questionnaires

2.1. Participants

There are numerous questionnaires: the Perceived Criticism Rating (PC, Hooley and Teasdale, 1989); the Parental Bonding Instrument (PBI, Parker et al., 1979, 1982); the Level of Expressed Emotion Scale (LEE, Cole and Kazarian, 1988); the Patient Rejection Scale (PRS, Kreisman et al., 1979); the Family Atmosphere Questionnaire (FEF, a questionnaire in German, Buchkremer and Fiedler, 1987; Lewandowski et al., 1989); and the Family Attitude Scale (FAS, Kavanagh et al., 1997).

The participants were relatives of inpatients who had been diagnosed with schizophrenia (for details see Section 3.1). The patients had to have been living in the same household with their relatives or their partner or spending at least 10 hyweek with them just before admission to the hospital. The first sample consisted of 76 relatives of 49 patients and the second of 79 relatives of 50 patients. Sample 1 served for item analysis and reduction of the number of items, and sample 2 for validation.

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Criteria for social class were measured according to Kleining (1975) and Kleining and Moore (1968). These classes are very much similar to those of Hollingshead and Redlich (1958). Sociological studies have shown that the structure of social class is very comparable between industrial countries (Moore and Kleining, 1960). Thus, the classification of Kleining and Moore is also transferable to the criteria of Hollingshead and Redlich. 2.2. Instruments 2.2.1. Camberwell Family Interview The EE status of the relatives was assessed with the Camberwell Family Interview (CFI, Leff, 1976) after the patient had been hospitalized. To this end, relevant behavioral patterns and events in the life of the patient during the 3 months preceding his or her hospitalization were discussed and the feelings and attitudes of the patient’s relatives with regard to these behavioral patterns and events were observed. The taped interviews were evaluated by two raters who had completed a 2-week training course run by one of the main authors of the CFI, Christine Vaughn. Blind reliability assessments revealed that levels of inter-rater agreement between the investigators and the criterion rater (C. Vaughn) were 0.88 and above (ns12 tapes) for the distinction between high- and low-EE relatives. If the relative expressed six or more critical comments, he was rated as high EE. The global index on the EOI scale ranges from 0 to 5. If the relative was rated 3 or higher on this scale, he was judged as high EE. 2.2.2. Family Questionnaire 2.2.2.1. Development of the preliminary version. The first step was to have experienced clinicians list common statements made by family members about a relative with schizophrenia and common ways of behaving with such a relative. In addition, statements were derived from EE-related concepts or were inspired by existing questionnaires, e.g. the PRS.

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The theoretical model of the EE condition was based on that developed by Vaughn and Leff (Vaughn and Leff, 1981; Leff and Vaughn, 1985) from qualitative content analyses of CFI interviews and yielding four characteristic attitudes or response styles in relatives: (1) the relative’s level of intrusiveness; (2) the relative’s emotional response; (3) the relative’s attitude toward the illness; and (4) the relative’s level of tolerance and expectations. The Vaughn and Leff model was supplemented by considerations of the relationship between high EE and inadequate coping strategies (Falloon et al., 1984; Goldstein et al., 1989). Based on such descriptive accounts and empirical investigations of EE dimensions, items were generated for the following areas: ‘intrusiveness’, ‘emotional response’, ‘attribution of illness’ and ‘coping skills’. Items relating to attitude and behavior areas recorded in the CFI were also included (CC, e.g. statements of dislike; EOI, e.g. excessively self-sacrificing). To achieve maximum correspondence with CFI categories, a number of items reflecting the CFI evaluation criteria (Leff and Vaughn, 1985) were generated for the areas of criticism and emotional overinvolvement. To minimize inaccurate responses resulting from the tendency to ‘social desirability’, the items were formulated so that they conceptualized negative responses not as a fault of the relative, but in terms of external attribution as a necessary corrective measure or outcome of excessive stress, e.g. ‘I have to try not to criticize himyher’. One item on the PRS appeared to meet these criteria and was therefore included in the EOI scale. To avoid stereotyped answers with a tendency towards the mean, only four possible answers ranging from ‘neveryvery rarely’ to ‘very often’ were allowed, with no middle value. The item pool was submitted to a team of EE experts, i.e. clinicians who had been trained as CFI raters by C. Vaughn or as FMSS raters by A. ˜ or both. These were experienced clinical Magana, psychologists and psychiatrists who were familiar with patients with schizophrenia, their relatives, and the EE literature. All of them had several years of experience in clinical work in psychiatry departments. All of them had already been engaged

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in family work with schizophrenia patients and their relatives. The items were evaluated for breadth of coverage, ease of understanding and acceptance. The preliminary version of the FQ administered to the relatives in sample 1 comprised 130 items.

Table 1 Parameters in the comparison between the FQ and the CFI

2.2.2.2. Development of the final version. The development of the final 20-item version is described in Section 2.3.

Lows‘favorable’ outcome; highs‘unfavorable’ outcome; a,b,c,dsabsolute frequencies; astrue negative; bsfalse negative; csfalse positive; and dstrue positive.

2.3. Statistical analysis

Provided that predictor and outcome are dichotomous, as in our case, the prognostic value of the predictor can be characterized by means of easily interpreted parameters. The data on the relation between prediction (FQ) and outcome (CFI) can be entered into a 2=2 table, such as is used in the x2 test. This table shows the numbers of hits and misses in classification, as well as the true and false positives and the true and false negatives, i.e. the types of hits and misses (see Table 1 for definition and Tables 4, 6, 7 and 9). In addition, we report the contingency coefficient and the phi coefficient. As the definitions of accuracy, sensitivity, specificity and positive and negative predictive value are not usually given in the literature, and these terms are often confused with each other, we provide the definitions we used (compare Gaebel et al., 1993; Bustillo et al., 1995). The accuracy or overall correct classification rate is calculated as the proportion of correct predictions: (aqd)y (aqbqcqd). This represents the main parameter for the quality of the prediction, i.e. it is the primary test of validity for the FQ. The proportion of correct predictions with regard to high or low CFI EE ratings is often defined using the parameters sensitivity wdy(bqd), true positivey(false negativeqtrue positive)x and specificity way(aq c), true negativey(true negativeqfalse positive)x. Some authors (Buchkremer et al., 1991; Holle, 1995) consider the predictive values for the prediction of CFI EE ratings to be better suited for use by clinicians. These values are defined as: ay (aqb) wtrue negativey(true negativeqfalse negative)x, the ‘favorable’ or negative prediction; and dy(cqd) wtrue positivey(false positiveqtrue pos-

The data were analyzed with SPSS for Windows, version 6.1.3. The pairwise missing option was used. Of the 130 items used in study 1, those 30 items were selected that had the highest correlations with CFI CC or CFI EOI. Since the relatives in study 2 took part in a variety of investigations, they had to participate in lengthy interviews and fill out many questionnaires in addition to the FQ. Therefore, we decided to use this shorter version of the FQ with this sample. A factor analysis was conducted using the responses to the pool of 30 items from both studies because the number of participants in the first study was too small for a reliable factor analysis. Principal components analysis was used for factor extraction. The scree test was used to determine how many factors to extract. Both orthogonal (varimax) and oblique (SPSS: oblimin) rotations were carried out to check for a possible strong interrelation among the resulting factors. In addition, the optimal factor solution was separately tested in each sample to evaluate stability. Sum scores of the final scales were calculated. Reliability (internal consistency) was evaluated by calculating Cronbach’s alpha for both the combined sample and the two samples separately. In study 1, the cut-off points defining low and high EE were determined that yielded the best agreement with the CFI EE ratings. These cut-off points were then applied in study 2. Significant group differences were determined by analysis of variance. Homogeneity of variance was checked using the Levene test.

FQ rating Low High

EE

CFI EE rating Low

High

a c

b d

G. Wiedemann et al. / Psychiatry Research 109 (2002) 265–279

itive)x, the ‘unfavorable’ or positive prediction (high CFI EE ratings are looked upon as ‘unfavorable’ outcome here). ‘Positive’ and ‘negative’ predictive values are used in the sense of clinical findings, where a ‘positive’ finding usually means that there is something unfavorable for the individual and a ‘negative’ finding that no pathology has been found. These formulas depend on the prevalence of high vs. low CFI EE ratings in the particular sample. Therefore, the predictive values calculated from one study should be used with caution in another study, i.e. in another sample of patients with possibly a very different distribution of high vs. low EE as assessed with the CFI. In the literature, negative predictive values are often mistaken for specificity and positive predictive values for sensitivity. When applying the concept of predictive values, an appropriate cut-off point for dichotomization has to be found. The above-mentioned parameters vary, depending on the specific value of this cutoff point: The higher the specificity, the lower the sensitivity and vice versa. Accuracy was taken as the criterion for optimal dichotomization, i.e. we chose the cut-off point yielding the maximum accuracy. In addition to analyzing the data using 2=2 tables and reporting phi coefficients of the binary EE judgements, we provide the Pearson correlations of the FQ CC scale with the frequency of CFI CC and of the FQ EOI scale with the nonbinary CFI EOI scale. Analyzing the data from members of the same family as if they were independent samples rather than correlated represents a methodological problem. This could be important for both the factor analyses and the EE classifications. Therefore, we combined samples 1 and 2, and took one randomly selected informant per family for the initial analysis. The results were then replicated with the second informant, who was again randomly selected in the case of three informants. The second sample will inevitably be small for a replication of the factor analysis, but it allows replication of the internal consistency of the FQ and of the CFI classification.

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3. Results 3.1. Sample characteristics Neither the patients in the two independent samples nor the relatives differed significantly in sociodemographic or clinical characteristics. The 99 patients in the combined sample (55 men, 44 women) had a mean age of 28 years wrange: 16– 54 years; standard deviation (S.D.): 9.8 yearsx. They had been diagnosed by a psychiatrist as having either schizophrenia (including ICD-9 295.0–295.3 and 295.6; 83%), or schizophrenia, schizoaffective type, with primarily schizophrenic symptoms (ICD-9 295.7; 17%) according to ICD9 (World Health Organization, 1978) and the Research Diagnostic Criteria (RDC, Spitzer et al., 1978). For 44 of the 99 patients, this was their first episode of schizophrenia; for 36, their second or third; and for 19, their fourth or more. Of the 155 relatives, 116 were parents and 39 were partners. The mean age of the 47 fathers was 56 years (S.D. 8.3 years); of the 69 mothers, 52 years (S.D. 7.0 years); and of the 39 partners (20 men, 19 women), 39 years (S.D. 11.2 years). With regard to socioeconomic status, 35 of the relatives (23%) were classified as lower class, 49 (32%) as middle class, and 71 (46%) as upper class. For 9 of the 155 relatives, there were missing data in the CFI rating. Of the remaining 146, 58 (40%) were classified as low EE and 88 (60%) as high EE; 23 (16%) were highly critical, 33 (23%) emotionally overinvolved, and 32 (22%) both highly critical and emotionally overinvolved. 3.2. Demographic correlates of the FQ scale The FQ scale criticism did not correlate with sex. The analysis of variance (ANOVA) yielded a mean of 21.1 for men (range 10–36) and 22.2 for women (range 10–39) (Fs0.92, Ps0.34). However, the FQ scale emotional overinvolvement did correlate with sex. The ANOVA yielded a mean of 25.7 for men (range 13–37) and 28.1 for women (range 18–37) (Fs9.00, Ps0.003). Thus, there is a sex difference in the FQ EOI score. Women scored significantly higher on the EOI scale compared to men, but this difference was

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also observed in the CFI score EOI. The CFI EOI scale significantly correlated with sex (x2s10.5, d.f.s1, Ps0.001). Again, many more women (56% of women) were coded high on the EOI scale in comparison to men (29% of men). This is a pattern that is very common, at least in Western societies. Men show much less emotional involvement in general than women. The FQ scores did not correlate with other demographic characteristics of the sample. The Pearson correlations of age with the FQ CC scale and the FQ EOI scale were not significant. The analysis of variance of the socioeconomic status and the FQ scores yielded no significant differences (Fs2.53, Ps0.08 for the CC score; Fs 0.88, Ps0.42 for the EOI score). 3.3. Test–retest reliability The interval over which the test was measured was 2 weeks. Test–retest correlation coefficients were Pearson’s rs0.84, P-0.001, Ns35 for the CC scale, and rs0.91, P-0.001 for the EOI scale. 3.4. Factor analysis 3.4.1. Factor analysis with 30 items The initial factor analysis with 30 items identified two factors that together accounted for 43.5% of the variance. The orthogonal and oblique solutions were comparable. The interrelation of the oblimin-rotated factors was 0.17. The first factor accounted for 30.8% of the variance. It consisted of 14 items, which were clearly related to the construct criticism (CC). The second factor explained 12.7% of the variance. It consisted of 16 items, which could be assigned to the construct emotional overinvolvement (EOI). The factor EOI appeared to be less homogeneous than the factor CC. There were more items that had somewhat higher loadings on the other factor. Before the second factor analysis, 10 items were deleted. Four were from the factor CC and had relatively high loadings on the factor EOI (‘There are things about himyher that annoy me,’ ‘Heyshe is a very difficult person,’ ‘I have to criticize himy her,’ and ‘Heyshe takes too much of my time’).

Six were from the factor EOI. Four of these also had relatively high loadings on the factor CC (‘I have given up a lot for himyher,’ ‘I keep trying to start a conversation with himyher,’ ‘Basically, hey she only has emotional problems,’ and ‘I like himy her very much’), and two had low loadings on both factors (‘I try to influence hisyher behavior,’ and ‘I enjoy being with himyher’). 3.4.2. Factor analysis with 20 items The second factor analysis with the remaining 20 items identified two factors that together accounted for 48.7% of the variance. Varimax (Table 2) and oblimin rotation yielded similar results. The oblique solution resulted in a correlation of the two factors of 0.19. The first factor, CC, explained 33.7% of the variance; Cronbach’s alpha was 0.92. As in the factor analysis with 30 items, the CC factor was very homogeneous. The second factor, EOI, accounted for 15% of the variance. Although this factor was less homogeneous, the resulting Cronbach’s alpha (0.80) was acceptable. Table 2 Results of the factor analysis with 20 items, varimax-rotated factor loadings Item number

Factor 1 Criticism

Factor 2 Emotional overinvolvement

20 4 8 12 18 14 6 16 2 10

0.850 0.806 0.786 0.757 0.750 0.745 0.718 0.712 0.701 0.641

0.029 0.079 0.105 0.133 0.064 0.065 0.134 0.049 0.175 0.142

13 3 5 7 1 11 19 15 9 17

0.103 0.223 0.005 0.241 0.299 y0.038 0.241 0.343 y0.085 y0.276

0.727 0.686 0.675 0.644 0.597 0.595 0.582 0.526 0.468 0.362

G. Wiedemann et al. / Psychiatry Research 109 (2002) 265–279 Table 3 FQ criticism scores: differences between relatives with high and low CFI criticism CFI criticism

N

FQ criticism scores Mean

S.D.

95% CI

Study 1 Low High Total

40 28 68

18.9 26.5 22.0

5.76 5.15 6.66

17.06–20.74 24.54–28.53 20.43–23.66

Study 2 Low High Total

45 25 70

19.9 23.9 21.3

5.84 5.85 6.11

18.13–21.64 21.46–26.30 19.86–22.77

The items of the factor EOI that had moderate loadings on the factor CC were ‘I thought that I would become ill myself’ (item 15) and ‘I tend to neglect myself because of himyher’ (item 1). In contrast, the item ‘Heyshe is an important part of my life’ (item 17) had a negative loading on the factor CC. Factor analyses for the two subgroups separately (studies 1 and 2) led to similar results. Cronbach’s alpha for the factor CC was 0.92 in study 1 and 0.91 in study 2, and for the factor EOI, 0.80 in study 1 and 0.78 in study 2. The final version of the questionnaire consists of two scales (‘FQ CC’ and ‘FQ EOI’) with 10 items each. (For an English translation of the original German, see Appendix A.) 3.5. Prediction of the CFI EE rating (criterionrelated validity) in study 1 We examined the correspondence between the FQ scores and the CFI EE ratings at two levels. First, we looked at whether the specific subtypes of high-EE attitudes (CC and EOI) were reflected in both instruments. We then examined whether a relative’s EE classification on the FQ was the same as on the CFI. The same procedure was applied in study 2. 3.5.1. Prediction of the CFI CC rating by the FQ CC score For eight of the 76 relatives in study 1, the sum score for the CC scale could not be calculated

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because of missing data on some items. The remaining 68 relatives had a mean CC score of 22 (S.D. 6.7; median 22). Those relatives rated high in CC on the CFI differed significantly in their FQ CC scores from those rated low (Fs31.5, P0.001; Table 3). The cut-off point for the FQ CC scale yielding maximum accuracy was a score of 23 (lowF23high). Of the relatives with a high CC score on the CFI, 68% were correctly predicted by the FQ CC scale wdy(bqd), sensitivityx, and of those with a low CC score on the CFI, 85% were correctly predicted by the FQ CC scale way(aqc), specificityx (Table 4). The accuracy of the FQ CC scale was 78% overall correct classifications (x2s19.8, d.f.s1, P-0.001, phis0.54, contingency coefficients0.47). 3.5.2. Prediction of the CFI EOI rating by the FQ EOI score For six of the relatives, the sum score for the EOI scale could not be calculated because of missing data on some items. The remaining 70 relatives had a mean EOI score of 28 (S.D. 4.9; median 28). Those relatives rated high in EOI on the CFI differed significantly in their FQ EOI scores from those rated low (Fs13.8, P-0.001; Table 5). The cut-off point yielding maximum accuracy was 27. Of the relatives classified as high EOI on the CFI, 80% were also classified thus on the FQ. Of the relatives classified as low EOI on the CFI, 64% were also classified thus on the FQ (Table 6). The overall correct classification rate was 71% (x2s13.3, d.f.s1, P-0.001, phis0.44, contingency coefficients0.40). Table 4 Comparison of FQ and CFI criticism classifications FQ criticism

CFI criticism Study 1

Study 2

Low

High

Low

High

Low High

34 6

9 19

34 11

11 14

Total

40

28

45

25

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Table 5 FQ EOI scores: differences between relatives with high and low CFI EOI

Table 6 Comparison of FQ and CFI EOI classifications FQ EOI

CFI EOI

N

FQ EOI scores

CFI EOI Study 1

Mean

S.D.

95% CI

Study 1 Low High Total

39 30 69

26.2 30.3 28.0

4.90 3.86 4.88

24.64–27.82 28.83–31.71 26.81–29.16

Study 2 Low High Total

40 30 70

24.6 28.3 26.2

4.63 4.19 4.79

23.12–26.08 26.73–29.87 25.04–27.33

3.5.3. Prediction of the CFI EE rating by the FQ EE score When the combined FQ scales were used as a measure of EE, there was a high degree of agreement between the FQ and CFI EE ratings (Table 7). On the FQ, participants were rated as high EE if their score on at least one of the two scales was above the cut-off point. Of the relatives who were classified as high EE on the FQ, more than three-quarters were also classified as high EE on the CFI (36 of 46, 78%; unfavorable result; positive predictive value). However, of those who were classified as low on the FQ, one-third were rated high on the CFI (8 of 24, 33%). The overall number of highs and lows did not differ very much between the two measures: 46 high-EE and 24 low-EE ratings on the FQ and 44 high-EE and 26 low-EE ratings on the CFI. The FQ correctly identified 36 of 44 relatives with a high-EE attitude (82%, sensitivity) and 16 of 26 relatives with a low-EE attitude (61.5%, specificity) as assessed with the CFI. In addition, it correctly identified 52 of 70 participants (74.3%) with respect to overall CFI ratings of EE (x2s 13.6, d.f.s1, P-0.001, phis0.44, contingency coefficients0.40).

Low

High

Low

High

Low High

25 14

6 24

33 7

14 16

Total

39

30

40

30

because of missing data on several items. The 75 remaining relatives had a mean CC score of 21.5 (S.D. 6.2; median 21). For five relatives in this study, no CFI rating was available. Those relatives who were rated high in CC on the CFI differed significantly in their FQ CC scores from those rated low (Fs7.5, Ps0.008; Table 3). Applying the cut-off point found in study 1 yielded the results shown in Table 4. The FQ CC scale correctly classified 14 of 25 relatives (56%) rated high in CC on the CFI and 34 of 45 relatives (75.6%) rated low. The overall correct classification rate was 68.6% (x2s7, d.f.s1, Ps0.008, phis0.32, contingency coefficients0.30). As expected in a validation study, the figures are somewhat lower than those in study 1. 3.6.2. Prediction of the CFI EOI rating by the FQ EOI score Here again there were four relatives without FQ EOI scores due to missing data. The mean score of the remaining 75 was 26.1 (S.D. 4.8; median 26). Again, for five relatives in this study, no CFI rating was available. Those relatives rated high in EOI on the CFI differed significantly in their FQ Table 7 Comparison of FQ and CFI EE classifications FQ EE

3.6. Prediction of the CFI EE rating (criterionrelated validity) in study 2 3.6.1. Prediction of the CFI CC rating by the FQ CC score For four of the 79 relatives in study 2, the sum score for the FQ CC scale could not be calculated

Study 2

CFI EE Study 1

Study 2

Low

High

Low

High

Low High

16 10

8 36

23 7

11 29

Total

26

44

30

40

G. Wiedemann et al. / Psychiatry Research 109 (2002) 265–279

EOI scores from those rated low (Fs11.8, Ps 0.001; Table 5). Of the 30 CFI high-EOI relatives, 16 (53.3%) were correctly classified with the FQ EOI, and of the 40 CFI low-EOI relatives, 33 (82.5%) were correctly classified (Table 6). Overall, 49 of the 70 relatives (70%) were correctly classified with the FQ EOI scale (x2s10, d.f.s1, Ps0.002, phis0.38, contingency coefficients0.35). 3.6.3. Prediction of the CFI EE rating by the FQ EE score When the combined FQ scales were used as a measure of EE as in study 1, 52 of 70 relatives (74.3%) were correctly classified (x2s16.6, d.f.s 1, P-0.001, phis0.49, contingency coefficients 0.44; Table 7). Of the 40 high-EE relatives on the CFI, 29 (72.5%) were correctly classified with the FQ, and of the 30 low-EE relatives, 23 (76.7%) were correctly classified. Of the 36 relatives who were classified as high EE on the FQ, 29, or more than 80%, received the same rating on the CFI (unfavorable result; positive predictive value). For the favorable results or negative predictive value, 23 of 34 classifications (68%) were correct. 3.7. Reanalysis of the combined sample taking the dependency of the observations into account 3.7.1. Replication of the factor analysis 3.7.1.1. Sample with one (sthe first) informant per family. Taking one randomly selected informant per family for the initial analysis of the combined sample (ssamples 1 and 2; see last paragraph in Section 2) yielded 95 cases. This initial factor analysis with the combined sample identified two factors that together accounted for 49.9% of the variance. The orthogonal and oblique solutions were comparable. The interrelation of the oblimin-rotated factors was 0.19. The first factor, CC, explained 36.3% of the variance. It consisted of 10 items, which were clearly related to the construct criticism. The second factor explained 13.6% of the variance. It consisted of the other 10 items, which could be assigned to the construct emotional over-

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Table 8 Results of the factor analysis with the sample with one informant per family, varimax-rotated factor loadings Item number

Factor 1 Criticism

Factor 2 Emotional overinvolvement

20 4 8 18 12 14 6 2 16 10

0.846 0.830 0.811 0.771 0.776 0.715 0.725 0.704 0.704 0.663

0.030 0.041 0.070 0.196 0.079 0.112 0.116 0.129 0.207 0.170

13 5 3 7 11 1 19 15 9 17

0.256 0.345 0.041 0.291 y0.090 0.251 y0.200 y0.217 0.348 0.334

0.736 0.679 0.689 0.643 0.604 0.540 0.465 0.267 0.565 0.518

involvement. Again, as in the previous analysis, the factor EOI appeared to be less homogeneous than the factor CC. There were more items that had somewhat higher loadings on the other factor. Thus, this factor reanalysis with a sample with independent observations yielded almost identical results compared to the previous factor analysis with a sample of potentially correlated observations. Table 8 shows the results of this factor analysis yielding not only two factors again with the identical items within each factor as in the previous analysis, but also with almost the same ranking of items within each factor. Within each factor, only the succession of two items is interchanged twice (items 12 and 18, and 16 and 2, within the CC factor; items 3 and 5, and 1 and 11, within the EOI factor; compare Tables 2 and 8). 3.7.1.2. Sample with the second informant per family. Taking the second randomly selected informant of the combined sample yielded 43 cases. This second factor analysis with the com-

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bined sample again identified two factors that together accounted for 48.1% of the variance. Varimax and oblimin rotation yielded similar results. The first factor explained 30.8% of the variance. Again, it consisted of 10 items, which were clearly related to the construct CC. The second factor accounted for 17.4% of the variance. The items were related to the construct EOI. Although again this factor was less homogeneous, the resulting Cronbach’s alpha coefficient (0.82) was acceptable. Thus, this exploratory factor reanalysis with a small sample with independent observations yielded almost identical results compared to our previous factor analyses with a bigger sample and with a sample of potentially correlated observations. This factor analysis again yielded two factors with the identical items within each factor as in the previous analyses. However, the sample size of this second sample is too small for an actual replication of the factor analyses. Therefore, this last factor analysis is exclusively exploratory. 3.7.2. Replication of the internal consistency of the FQ and of the CFI classification 3.7.2.1. Internal consistency. Reliability was evaluated by calculating Cronbach’s alpha for the sample with one informant and for the sample with the second informant. The reliability coefficient of the first sample was 0.92 for the CC scale and 0.79 for the EOI scale, whereas for the second sample it was 0.90 for CC and 0.82 for EOI. 3.7.2.2. Correspondence between FQ and CFI classification. We examined whether a relative’s EE classification on the FQ was the same as on the CFI. The same procedure was applied in both samples. Using the combined FQ scales as a measure of EE, there was a high degree of agreement between the FQ and CFI EE ratings in the sample with one informant (i.e. the first informant): 73 of 95 relatives (76.8%) were correctly classified (x2s 26.2, d.f.s1, P-0.001, phis0.53, contingency coefficients0.46, Table 9). Of the 55 high-EE relatives on the CFI, 44 (80%) were correctly

Table 9 Comparison of FQ and CFI EE classifications in samples with independent observations FQ EE

CFI EE Sample 1

Sample 2

Low

High

Low

High

Low High

29 11

11 44

10 6

8 19

Total

40

55

16

27

Sample 1, sample with one randomly selected informant per family; sample 2, sample with the second randomly selected informant per family.

classified with the FQ, and of the 40 low-EE relatives, 29 (72.5%) were correctly classified. In the sample with the second randomly selected informant, the FQ correctly identified 19 of 27 relatives with a high-EE attitude (70.4%, sensitivity) and 10 of 16 relatives with a low-EE attitude (62.5%, specificity) as assessed with the CFI. It correctly identified 29 of 43 participants (67.5%) with respect to overall CFI ratings of EE (x2s 4.46, d.f.s1, Ps0.035, phis0.32, contingency coefficients0.31; Table 9). When we further divided the sample with one, i.e. the first informant, into the two samples corresponding to our two original studies 1 and 2, 34 of 45 relatives (75.5%) were correctly classified (x2s10.1, d.f.s1, Ps0.002, phis0.47, contingency coefficients0.43) in study 1, whereas 39 of 50 relatives (78%) were correctly classified (x2s15.6, d.f.s1, P-0.001, phis0.56, contingency coefficients0.49) in study 2. As the sample with the second informant was comparatively small, we did not subdivide it further. 3.8. Non-binary relationship of the FQ to the CFI In addition to analyzing the data using 2=2 tables and reporting phi coefficients, information about how well the FQ CC scale correlated with the frequency of CFI CC is of interest. The correlation was Pearson’s rs0.44, P-0.001. Accordingly, the correlation of the FQ EOI scale with the non-binary CFI EOI scale was Pearson’s rs0.42, P-0.001.

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4. Discussion The present study outlines the development and validation of the Family Questionnaire (FQ), a brief self-rating scale for assessing the EE status of relatives of schizophrenic patients. The questionnaire took only minutes to fill in and was highly acceptable to the relatives who were completing it. Even though the cut-off scores from study 1 were used in study 2, the overall correct classification rate for EE remained unchanged. The rate did not go down in study 2, as frequently happens in validation studies. These results were again shown in a reanalysis with data from members of the same family as independent samples. The samples from studies 1 and 2 were combined and one informant per family was randomly selected for the first reanalysis, the second informant for a replication of this reanalysis. Both the reanalysis of the factor analyses and the replication of the internal consistency of the FQ and of the CFI classification revealed consistent results with the data from studies 1 and 2. Thus, this validation can be regarded as being successful. The FQ seems to be a promising new scale. Furthermore, to the best of our knowledge, the FQ is the only questionnaire so far to have consistently yielded significant correlations with CFI EOI. The overall correct classification rate reported ˜ et al., 1986). In for the FMSS is 75% (Magana Germany, it is 73% in independent studies (Leeb et al., 1991; Stark and Buchkremer, 1992). With our 74% for the FQ in both the original sample and the validation sample, we have achieved the same level of accuracy. However, the FMSS requires more time and effort than the FQ: (1) it is not a self-rating scale, so an interviewer is required; (2) the speech sample has to be taped; (3) the tape has to be scored; (4) raters have to be trained to score the speech sample correctly; (5) raters have to be monitored for reliability; and (6) evaluation time is approximately 30 min for trained raters. Furthermore, the FMSS requires that the relatives be willing to have their speech audiotaped.

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Therefore, the FQ is a more cost-effective instrument. Thus, it is as good as the FMSS, with approximately the same overall correct classification rate, but can be used with a broader range of participants. According to Miklowitz and Goldstein (1993), short measures of EE are perhaps best viewed as probes for high-EE attitudes rather than as a total substitute for the full CFI. Because the FMSS underestimates high EE, some authors (e.g. Miklowitz and Goldstein, 1993) have argued that it may not be long enough (or sensitive enough) to capture those high-EE attitudes that become apparent only after a certain degree of rapport has developed between the interviewer and the relative. Capturing these attitudes might not be achievable with a short speech sample, or even with a self-report questionnaire. However, the FQ is much better at identifying high EE than the FMSS (sensitivity 48–65%; ˜ et al., 1986; Leeb et al., 1991; Stark and Magana Buchkremer, 1992), even though it is shorter and involves only a self-rating. Since the quality of predictions depends on a good balance between sensitivity and specificity, the predictive results presented are more satisfactory than those from other brief measures for assessing EE. The FMSS predicts low EE successfully (high specificity), but does not do well on high EE (low sensitivity), whereas the FQ predicts high and low EE almost equally well (high sensitivity and moderate-to-high specificity). In terms of (unfavorable) positive predictive value and (favorable) negative predictive value, the results of all FMSS studies and of this FQ study are comparable. The positive predictive value of both instruments is approximately 80% and the negative predictive value approximately 70% (see Table 7 for the FQ). Although we think that it has been a reasonable way of coping with the problem of workload, since the relatives in study 2 only rated the 30 items that had been identified from study 1, this procedure might have led to a limitation. Ideally, it could be argued that the full 130-item set should again have been used for study 2. Sample-specific variance could result in slightly different sets of items from the total of 130 being better correlates of EE in study 1 and study 2. By restricting the

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pool of items used in study 2, the upper limit of the criterion validity of the scale may have been restricted. A further small point is that the negative nature of the questions might mean that the FQ is subject to a negative response bias. The FQ EOI scale appears to be more heterogeneous than the FQ CC scale. This was to be expected, since the EOI construct is more complex and less clearly defined than the CC construct. It involves overconcern, overidentification and overprotectiveness. Either all three, or two, or only one of these facets may be present in various forms in relatives with high EOI scores. Hence, the highscoring population may be diverse. Moreover, the CFI and the FQ, or perhaps any ratings by outside observers and self-rating measures, may be addressing different aspects of EOI. Further clarification of the relevant aspects of EOI is therefore needed. But despite these caveats, the FQ yielded a relatively good prediction of CFI EOI with its EOI scale in both studies 1 and 2. The main cause of misclassifications may be the generally poor agreement between self-ratings of behavior and ratings by outside observers. With this in mind, our results are encouraging. Moreover, self-ratings need not necessarily explain exactly the same amount of variance of a construct as ratings made by others. The overall misclassification might not be an error, but instead an indication that the FQ measures different aspects of the EE construct than the CFI. EE misclassifications of relatives based on questionnaires may not necessarily lead to incorrect ratings of the risk of relapse. Rather, a cover-up tendency may be less pronounced with a selfrating method than in a face-to-face interview. The face-to-face nature of the interview may inhibit relatives from voicing concern or criticism that they would express more freely in their responses on a questionnaire (Docherty et al., 1990). If this is true, then some relatives’ attitudes may actually be reflected more accurately in their responses to a questionnaire than in their interview scores. Of course, the assumption made here must be considered hypothetical.

On the other hand, a significant correspondence between FQ EE and CFI EE does not automatically imply that the questionnaire also has predictive validity in relation to relapse, especially as the predictive validity of the CFI itself is not perfect. Hooley and Richters (1991) had raters with no training in evaluating the CFI assess the EE status of relatives based on CFI tapes and using a Q-sort method. Although the authors reported good agreement between the Q-sort rating and the CFI variables CC, hostility and warmth (and to a lesser extent also EOI), the Likert-scale ratings did not predict risk of relapse. The results of this study highlight the importance of establishing both the concurrent and predictive validity of any alternative measure of EE. Thus, a limitation of the present study is the lack of data concerning the predictive validity of the FQ. The cautionary note included by Hooley and Richters (1991) in their article can also be applied to the FQ: significant correlates of EE will not necessarily be good predictors of relapse. The predictive validity of any alternative measure has to be demonstrated rather than assumed. In the absence of data that demonstrate predictive validity, both clinicians and researchers must be circumspect about using significant correlates of EE as EE substitutes. As a measure of EE, self-reports may even be rather poor, while as a predictor of relapse, they may hold considerable promise (Hooley and Teasdale, 1989). Further studies on the predictive validity of questionnaires are therefore needed to clarify whether the CFI and the brief method given predict the same or different proportions of relapse variance. In the latter case, a combination of the CFI and a brief method might lead to an increase in predictive validity, as might a combination of the FQ and another brief method, such as the FMSS. Miklowitz and Goldstein (1993) suggested that a good combination of methods might ultimately provide the best prediction. A combination such as the CFI during the patient’s hospital stay and a short questionnaire after discharge might predict a relapse more reliably than either assessment alone: a pattern of stable high EE into the post-discharge period might put a patient at a greater risk for

G. Wiedemann et al. / Psychiatry Research 109 (2002) 265–279

relapse than an unstable pattern, such as high-tolow, or vice versa. In summary, the FQ is an instrument for assessing EE that had 74% agreement with the CFI classifications of relatives in both samples 1 and 2. Overall, the results provide reasonably good preliminary evidence of the construct validity of the FQ. The instrument could be a valuable research tool, both for easier assessment of EE and for refinement of the construct. Showing that the FQ correlates with the CFI represents a good first step. However, the next test for the scale will be its ability to predict relapse, i.e. to identify patients at high risk of relapse. Although further validation studies are needed, in particular with respect to the predictive utility of the scale in relation to relapse, the findings presented suggest that the FQ has a clear factor structure, good internal consistency of subscales and acceptable relationship to the Camberwell Family Interview. Thus, it extends the existing literature on self-report measures of expressed emotion. Acknowledgments The authors are grateful to their colleagues at the Max Planck Institute of Psychiatry, Munich, ¨ Dr. G Hank, and Dr. U. Dr. M. Dose, Dr. H. Durr, ¨ Muller, and thank patients and relatives for their help and co-operation. We are also grateful for the comments of two anonymous reviewers. This study was supported by the German Ministry of Research and Technology (BMFT). Appendix A: Family Questionnaire (FQ)

Nevery Rarely Often Very very often rarely 1 2 3 4 5

6 7 8 9

10

11 12 13 14 15 16

17 18 19

Name: Date: This questionnaire lists different ways in which families try to cope with everyday problems. For each item please indicate how often you have reacted to the patient in this way. There are no right or wrong responses. It is best to note the first response that comes to mind. Please respond to each question, and mark only one response per question.

277

20

I tend to neglect myself because of himyher I have to keep asking himyher to do things I often think about what is to become of himyher Heyshe irritates me I keep thinking about the reasons for hisyher illness I have to try not to criticize himyher I can’t sleep because of himyher It’s hard for us to agree on things When something about himyher bothers me, I keep it to myself Heyshe does not appreciate what I do for himy her I regard my own needs as less important Heyshe sometimes gets on my nerves I’m very worried about himyher Heyshe does some things out of spite I thought I would become ill myself When heyshe constantly wants something from me, it annoys me Heyshe is an important part of my life I have to insist that hey she behave differently I have given up important things in order to be able to help himyher I’m often angry with himyher

O

O

O

O

O

O

O

O

O O

O O

O O

O O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

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