Controllability perceptions and reactions to symptoms of schizophrenia: a within-family comparison of relatives with high and low expressed emotion.

In a sample of 35 family members of patients with recent-onset schizophrenia, attributions of control and the content of critical comments were compared for 2 relatives of the same household who held discrepant expressed emotion (EE) attitudes (1 high and 1 low) toward their mentally ill family member. Attributions and the content of critical comments were also compared for low-EE relatives from low-EE homes versus low-EE relatives from high-EE homes. Our results indicate that high-EE relatives tend to attribute more control over behavior to patients than do low-EE relatives of the same patient. In addition, low-EE relatives from high-EE homes attribute more behavioral control to patients than do low-EE relatives from low-EE homes. These findings suggest that EE status is linked to attributions of control over behaviors, but additional patient factors or influences among family members may also affect EE attitudes.

Attributions and affective reactions of family members and course of schizophrenia.

The authors tested an attribution-affect model of schizophrenic relapse attending to the role of families' positive affect (warmth) and negative affect (criticism). Coders listened to interviews of 40 family members taken from C. E. Vaughn, K. S. Synder, S. Jones, W. B. Freeman, and I. R. Falloon (1984) and rated their attributions of controllability for the symptoms and behaviors of their relatives with schizophrenia. For family members not designated as emotionally overinvolved, perceptions that their ill relatives' symptoms and behaviors were under the patients' control were related to family members' warmth and criticism and to patients' clinical outcomes. Of the affective reactions, only criticism predicted outcome. In addition, patients' use of street drugs was related to attributions, criticism, and outcome. Together these findings suggest that families' attributions and criticism are important in understanding the relationship between family factors and course of illness.

Expressed emotion, attributions, and schizophrenia symptom dimensions.

Using a sample of 40 Anglo American family members of schizophrenic patients, the present study replicates and lends cross-cultural support for an attribution-affect model of expressed emotion (EE). Consistent with attribution theory, the authors found that highly critical relatives (high-EE) viewed the illness and associated symptoms as residing more within the patient's personal control as compared with less critical relatives (low-EE). A content analysis classified the types of behaviors and symptoms most frequently criticized by relatives. Symptoms reflecting behavioral deficits (e.g., poor hygiene) were found to be criticized more often than symptoms reflecting behavioral excesses (e.g., hallucinations). In line with an attribution-affect framework, relatives may be less tolerant of behavioral deficits because they are viewed as intentional, whereas behavioral excesses are easily recognized as core symptoms of mental illness.

Expressed emotion, perceived criticism, and relapse in depression: a replication in an Egyptian community.

OBJECTIVE: The aims of this study were to determine the value of families' expressed emotion and patients' perception of family criticism in predicting relapse in Egyptian depressed patients and to evaluate transcultural differences in assessment of these measures. METHOD: The subjects were 32 consecutive depressed patients from psychiatric clinics in Cairo and Ismailia, Egypt, who fulfilled the DSM-III-R criteria for major depression or bipolar disorder. An Arabic version of the Camberwell Family Interview was administered to key relatives of the depressed patients. Rating of expressed emotion was performed blindly by a qualified rater to assess levels of criticism, hostility, emotional overinvolvement, warmth, and positive remarks. Patient perception of family criticism (perceived criticism) was also assessed. All patients were followed up for 9 months to assess relapse and compliance with treatment. RESULTS: The relation of family criticism to relapse was statistically significant. Although this result replicates previous findings, the criticism level that best differentiated relapsers and nonrelapsers was a score of 7, which is much higher than previously reported in Western studies. This relation was not observed for other expressed emotion components. Also, no association between perceived criticism and relapse was detected. CONCLUSIONS: Expressed emotion is a prognostic factor that should be assessed with consideration of the specific culture and intrafamilial patterns. The use of perceived criticism in the prediction of relapse in depression is questionable. There is a need for a simplified, less time-consuming assessment tool that takes cross-cultural differences and specificities into consideration.

The vulnerability/stress model of schizophrenic relapse: a longitudinal study.

A tentative model for conceptualizing the interplay of vulnerability factors, stressors, and protective factors in the course of schizophrenia is discussed. A study of the initial years after a first schizophrenic episode is testing the predictive role of key factors. During an initial 1-year period of depot antipsychotic medication, independent life events and expressed emotion were found to predict the likelihood of psychotic relapse. Initial analyses indicate that independent life events play less of a role in relapse prediction during a medication-free period. These results suggest that maintenance antipsychotic medication raises the threshold for return of psychotic symptoms, such that relapses are less likely unless major environmental stressors occur. A low expressed emotion environment may be a protective factor.

Developmental Processes in Schizophrenic Disorders: longitudinal studies of vulnerability and stress.

The Developmental Processes in Schizophrenic Disorders project is a longitudinal study of schizophrenic patients who have recently had a first episode of psychosis. The project focuses on discriminating characteristics of schizophrenic patients that are "stable vulnerability indicators," "mediating vulnerability factors," and "episode indicators" by comparing normal subjects to schizophrenic patients assessed in clinically remitted and psychotic states. A parallel project goal is to identify predictors of relapse, social and work impairment, and illness course among potential psychobiological vulnerability factors and environmental potentiating factors. Hypothesized vulnerability factors and potential environmental stressors are examined first under standardized maintenance antipsychotic medication conditions for at least 1 year. Patients showing stable remission of psychosis after 1 year of maintenance antipsychotic medication are invited to enter drug crossover and withdrawal protocols to determine the need for continuous antipsychotic medication. Vulnerability and stress factors are again assessed. A summary of results to date is presented. Deficits in early components of processing visual arrays and in sustained discrimination of successive ambiguous perceptual inputs are relatively stable across psychotic and clinically remitted states in the schizophrenic patients. Performance on a vigilance task demanding active, working memory also remains abnormal during clinical remission but covaries significantly with psychotic state and is a candidate for a mediating vulnerability factor. Autonomic activation level does not appear to be an enduring vulnerability factor, but it predicts the extent of short-term symptomatic recovery and may mediate the impact of stressors. Under conditions of standardized, injectable antipsychotic medication, independent stressful life events and highly critical attitudes toward the patient in the social environment predict relapse risk. Prospective data suggest that signs and symptoms prodromal to psychotic relapse may be present in about 60 percent of patients.

Is expressed emotion an index of a transactional process? I. Parents' affective style.

The degree to which expressed emotion (EE) attitudes in key relatives reflect ongoing transactional processes in families is a topic of controversy. The associations between EE attitudes, as measured during an acute hospitalization (using the Camberwell Family Interview) and during the aftercare period (using 5-minute speech samples), and interactional behavior in parents of recent-onset schizophrenics (this article) and in patients themselves (second article), were investigated. In the first study, EE attitudes manifested by parents during the aftercare period were stronger correlates of their interactional behaviors during the aftercare period than were EE attitudes measured during the inpatient period, despite the frequent correspondence between the two EE measures. The pattern of attitudes shown between the inpatient and outpatient periods also predicted transactional styles in parents during the outpatient period, findings not accounted for by clinical attributes of patients. When high-EE attitudes persist during the aftercare period and are reflected in transactional behaviors, the risk for subsequent patient relapse may be enhanced.

The initial onset of schizophrenia and family expressed emotion. Some methodological considerations.

The relationships between duration of schizophrenic illness before first hospital admission, expressed emotion in key relatives, and illness course have yielded conflicting reports. This study examined the issue from a methodological perspective in a sample of first-episode schizophrenic patients. A 'best estimate' of illness onset, based on a compilation of all sources, was compared with an estimate based on parental report. Parental estimates suggested that the children of high-EE parents had been ill for significantly longer, but this difference was not confirmed by the best estimate. In most cases, the ill children of high-EE parents were living at home before hospital admission and their parents' estimates of duration were quite accurate. In the few cases in which the child was living away from home, high-EE parents strikingly overestimated duration. Children of low-EE families were more likely to be living away from home, but this factor did not explain the consistent underestimates of duration made by their parents. Although duration of illness did not relate to EE, successful engagement in out-patient before in-patient treatment was more common among children from low-EE families.

Expressed emotion and patient-relative interaction in families of recent onset schizophrenics.

This article examines the interaction patterns of relatives of young, recent onset schizophrenic patients classified as displaying either high or low expressed emotion (EE) by two measures, the original Camberwell interview method and a recently developed brief method. The former was administered during the hospitalization period and the latter was administered approximately 2 months later when the patient was in the community. Family interactions were coded with an observational coding system that permitted sequential patterns to be analyzed as a function of the EE status of the family. No relation between the Camberwell EE rating and interactional behavior was found. However, high EE-critical relatives, defined by the brief EE method, were more negative in direct interactions than low EE relatives or high EE relatives classified as emotionally overinvolved. Sequential analyses indicated that high EE-critical relatives showed extreme negative escalation patterns. Patients' reactions to high EE-critical relatives were characterized by self-justification and negative nonverbal behavior.

Family factors and the course of bipolar affective disorder.

Measures of family attitudes (expressed emotion [EE]) and interactional behaviors (affective style [AS]), both of which have been found to predict relapse in schizophrenia, were obtained from key relatives of 23 hospitalized recently manic bipolar patients. Patients were then followed up for a period of nine months after hospital discharge and rated on measures of clinical course, social adjustment, and medication compliance. Levels of intrafamilial EE and AS were found to predict likelihood of patient relapse at follow-up, especially when used as conjoint predictors of patient outcome status. Levels of AS also predicted degree of social adjustment at follow-up. The predictive relationships observed were independent of patient medication compliance, treatment regimen, baseline symptoms, demographics, and illness history. Results suggest that the emotional atmosphere of the family during the postdischarge period may be an important predictor of the clinical course of bipolar disorder.

The impact of education about schizophrenia on relatives varying in expressed emotion.

The demand for information by relatives and the success of family intervention programs with an initial didactic component has resulted in a proliferation of educational interventions in schizophrenia. The present study assesses the impact of a single educational session on relatives of recent-onset schizophrenic patients. Results suggest that relatives who participated in family education experience an increased sense of support from the treatment team and a nearly significant tendency toward a decrease in self-blame regarding the schizophrenic illness. Despite findings in previous studies suggesting information acquisition immediately after education and retention after 6 months, the present study found no information retention after a 2-month period. After family education, relatives rated as high in expressed emotion (EE) reported a significantly increased sense of understanding of the illness and expressed increased feelings of support from the treatment team, whereas low EE relatives did not change significantly in these attitudes as a function of the educational session. Low EE relatives demonstrated more actual information about the illness and were less likely to perceive the symptoms as being done intentionally to bother them.

Family factors in schizophrenic relapse. Replication in California of British research on expressed emotion.

Our study of the emotional atmosphere of the homes of schizophrenic patients in southern California has replicated British findings concerning the influence of the family environment on the course of schizophrenia. As in the British studies, criticism and overinvolvement expressed by a key relative about the patient at the time of the key admission proved to be the best single predictor of symptomatic relapse in the nine months after discharge from the hospital. Replicating the British results, the association between relatives' expressed emotion and relapse was independent of all other variables investigated. Cross-cultural results concerning the prophylactic effects of medication suggest that clinicians should look to the emotional atmosphere in the home for explanations of medication failures.

Effect of eye closure, mental concentration, and nonauditory sensory stimulation on the threshold and magnitude of the acoustic reflex.

Acoustic reflex threshold and magnitude were measured for normal-hearing subjects in four experiments under conditions of: (1) tight and relaxed eyelid closure; (2) eyes open and closed in light, focusing on a spot, reading, and solving a visual maze; (3) tactile stimulation; and (4) performing a mental task. Measurements were susceptance change in millimhos for a 220 Hz probe tone. A 1000 Hz pure-tone and broadband noise presented contralaterally were the stimuli. All factors affected reflex results. Eyelid closure enhanced reflex responses with tight closure involving voluntary muscle tension having a greater effect than relaxed closure. Both passive and active visual tasks suppressed the reflex. The mental task resulted in suppression of both reflex threshold and magnitude. Vibrotactile stimulation also resulted in a suppressed reflex. Changes were more pronounced with broadband noise as the reflex eliciting stimulus. Clinical implications are discussed.

Family factors in schizophrenic relapse: a replication.

Family factors have been reported to influence the course of schizophrenia. In a replication of British studies, schizophrenic patients from the Los Angeles area were evaluated for symptomatic relapse 9 months after hospital discharge as a function of the level of "expressed emotion" in their relatives. In striking confirmation of the British findings, patients who came from families that were excessively critical, emotionally overinvolved, or both were much more likely to relapse than their counterparts who came from more tolerant and accepting families.

The effect of bicycle seat height variation upon oxygen consumption and lower limb kinematics.

VO2 was obtained for 10 women bicycling on rollers at 3 saddle heights (SH), 95, 100 and 105% trochanteric height. Kinematic patterns described by the hip, knee, ankle and foot were discerned from one pedal cycle at each of the 3 SH. Subjects cycled on a Fuji Dynamic 10 10-speed bicycle, at 60 rpm, (a work load of 799 kpm/min was applied by a tensioning belt from a bicycle ergometer) until they reached steady state. Expired air was then collected and cine films were taken during gas collection. The 100% SH was most efficient, mean values for 95, 100 and 105% SH were 1.69, 1.61 and 1.74 lit/min, respectively. Kinematic patterns showed no variation in the range of motion (ROM) at the hip, values at the dead centers (DC) did change. The ROM at the knee varied from 69 to 82.9 degrees, 95 to 105% SH, values at the DC varied also. Plantar flexion (PF) at bottom dead center increased by 10% from 95 to 105% SH. Foot angle showed no significant variation with increasing SH. The major adaptations to increases in SH are found at the knee and in ankle PF.