Long-term stability of communication deviance.

Communication deviance (CD), forms of communication that are not bizarrely thought disordered but are hard to follow and that make difficult the consensual sharing of attention and meaning, has been hypothesized as a nonspecific contributor of rearing parents to psychopathology of offspring, including schizophrenia. This hypothesis, or an alternative of genetic transmission, would gain plausibility if CD has long-term stability. CD was evaluated, using tape-recorded and reliably scored Rorschachs in 158 Finnish adoptees, and retested after a median interval of 11 years. Adolescent CD was not stably correlated with follow-up CD. However, initial CD at a mean age of 32 and follow-up CD were significantly correlated. Gender, genetic risk for schizophrenia, and DSM-III-R (American Psychiatric Association, 1987) psychiatric diagnoses had no effect on adult CD stability. CD appears to be a stable, traitlike feature of adult but not adolescent functioning.

Finnish adoptive family study: sample selection and adoptee DSM-III-R diagnoses.

OBJECTIVE: To evaluate the genetic contribution to schizophrenia using an adoption design that disentangles genetic and environmental factors. METHOD: Finnish hospital diagnoses of schizophrenic/paranoid psychosis in a nationwide sample of adopting-away women are compared with DSM-III-R research diagnoses for these mothers. DSM-III-R diagnoses of their index offspring are blindly compared with adopted-away offspring of epidemiologically unscreened control mothers. RESULTS: Primary sampling diagnoses of index mothers were confirmed using DSM-III-R criteria. Lifetime prevalence of typical schizophrenia in 164 index adoptees was 6.7% (age-corrected morbid risk 8.1%), significantly different from 2.0% prevalence (2.3% age-corrected morbid risk) in 197 control adoptees. When adoptees with diagnoses of schizoaffective disorder, schizophreniform disorder, schizotypal disorder and affective psychoses were added, the contrast between the index and control adoptees increased. CONCLUSION: The genetic liability to 'typical' DSM-III-R schizophrenia is decisively confirmed. Additionally, the liability also extends to a broad spectrum of other psychotic and non-psychotic disorders.

Thought disorder index of Finnish adoptees and communication deviance of their adoptive parents.

BACKGROUND: Diverse forms of thought disorder, as measured by the Thought Disorder Index (TDI), are found in many conditions other than schizophrenia. Certain thought disorder categories are primarily manifest during psychotic schizophrenic episodes. The present study examined whether forms of thought disorder qualify as trait indicators of vulnerability to schizophrenia in persons who are not clinically ill, and whether these features could be linked to genetic or environmental risk or to genotype-environment interactions. The Finnish Adoptive Study of Schizophrenia provided an opportunity to disentangle these issues. METHODS: Rorschach records of Finnish adoptees at genetic high risk but without schizophrenia-related clinical diagnoses (N = 56) and control adoptees at low genetic risk (N = 95) were blindly and reliably scored for the Thought Disorder Index (TDI). Communication deviance (CD), a measure of the rearing environment, was independently obtained from the adoptive parents. RESULTS: The differences in total TDI between high-risk and control adoptees were not statistically significant. However, TDI subscales for Fluid Thinking and Idiosyncratic Verbalization were more frequent in high-risk adoptees. When Rorschach CD of the adoptive rearing parents was introduced as a continuous predictor variable, the odds ratio for the Idiosyncratic Verbalization component of the TDI of the high-risk adoptees was significantly higher than for the control adoptees. CONCLUSIONS: Specific categories of subsyndromal thought disorder appear to qualify as vulnerability indicators for schizophrenia. Genetic risk and rearing-parent communication patterns significantly interact as a joint effect that differentiates adopted-away offspring of schizophrenic mothers from control adopted-away offspring.

Effects of group treatment for women with a history of childhood sexual abuse.

OBJECTIVE: Empirical support for the effectiveness of group therapies for women with a history of childhood sexual abuse is scant. This study examined the feasibility of conducting abuse-focused research and group treatment on a short-term unit and evaluated the effectiveness of the Women's Safety in Recovery group. METHODS: Eighty-six women with a history of childhood sexual abuse participated in treatment as usual (N=38) or in the Women's Safety in Recovery group (N=48). The latter group met three times weekly for one hour, focusing on patients' current safety and self-care. Participants completed the Symptom Checklist-Revised at baseline, discharge, and six-month follow-up. Patients rated their experience in treatment at discharge and six-month follow-up, and therapists rated patients' treatment experiences at discharge. The feasibility of the treatment group was measured by enrollment rates, group attendance, and attrition. RESULTS: Eighty-two percent of eligible patients agreed to enroll in the study. Women's Safety in Recovery participants attended an average of ten group meetings. Seventy percent of enrollees completed discharge assessments, and of these, 82 percent completed the six-month follow-up. Compared with treatment-as-usual patients, Women's Safety in Recovery participants reported greater symptom improvement and reported that their childhood sexual abuse issues had been more thoroughly addressed. These differences were present at discharge and at six-month follow-up. Therapists also perceived that abuse issues of these participants had been more thoroughly addressed. CONCLUSIONS: Women's Safety in Recovery participants reported significant reductions in distress compared with those receiving treatment as usual. The abuse-focused research program and the Women's Safety in Recovery group proved feasible, despite attrition.

Women's safety in recovery: group therapy for patients with a history of childhood sexual abuse.

The literature on group therapies for women with histories of childhood sexual abuse has focused on outpatient treatments. A model of group treatment for inpatients and partial hospital patients is described here. "Women's Safety in Recovery" is a first-stage trauma recovery group that promotes mastery of current life stressors and prevents regression through the use of psychoeducation about abuse effects, the practice of problem-solving skills, and supportive, topic-focused discussion. The group is structured in three one-week modules that patients can begin or leave at any time.

Gene-environment interaction in vulnerability to schizophrenia: findings from the Finnish Adoptive Family Study of Schizophrenia.

OBJECTIVE: This study assessed the interaction of genetic risk and rearing-family risk as a subsyndromal test measure of schizophrenic thought disorder in adoptees. METHOD: A group of 58 adoptees with schizophrenic biological mothers was compared with 96 comparison adoptees at ordinary genetic risk; putative adoptee vulnerability was assessed blindly and reliably by using the Rorschach Index of Primitive Thought. Environmental risk was measured by using frequency of communication deviance as a continuous variable, scored independently from Rorschach assessments of the adoptive parents. RESULTS: High genetic risk in itself was not associated with greater vulnerability to schizophrenic thought disorder in the adoptees, as indicated by the Index of Primitive Thought. Also, greater communication deviance in the adoptive parents was not associated with greater thought disorder in the comparison adoptees. However, there was a highly significant gene-environment interaction. Among the offspring of the adoptive parents with high levels of communication deviance, a higher proportion of high-risk than comparison adoptees showed evidence of thought disorder. In contrast, among the offspring of adoptive parents with low communication deviance, a lower proportion of high-risk than comparison adoptees showed evidence of thought disorder. The distribution of communication deviance scores did not differ significantly between the adoptive parents of high-risk offspring and the adoptive parents of comparison offspring. CONCLUSIONS: The findings are consistent with genetic control of sensitivity to the environment. There is no evidence that high genetic risk of schizophrenia among offspring is associated with high levels of communication problems in rearing parents.

Disqualifying family communication and childhood social competence as predictors of offspring's mental health and hospitalization. A 10- to 14-year longitudinal study of children at risk of psychopathology.

Forty-nine families from the University of Rochester Child and Family Study were followed up 10 to 14 years after initial assessment. Two inclusion criteria were applied: at least one of the parents had been hospitalized for a functional psychiatric disorder before initial assessment and, second, the male index offspring should be 18 years or older at follow-up. Initial measures included observationally based coding of the family's level of disqualifying communication toward the index offspring, index child's scores on the Child Manifest Anxiety Scale, and ratings of the index child's social competence carried out by peers, teachers, and parents. Offspring outcome was measured by the Mental Health Inventory, Global Assessment Scale (GAS), and hospitalization for psychiatric disorder. The results showed that every measure of offspring outcome was predicted by the amount of disqualification directed to the offspring from the other family members. In addition, GAS score and mental health were predicted by the offspring's competence as a child. Family disqualification, childhood competence, and socioeconomic status accounted for 63% of the variance in adult GAS scores.

Confirmatory and disconfirmatory family communication as predictor of offspring socio-emotional functioning. A 10 to 14 year follow-up of children at risk.

Forty-nine families from the University of Rochester Child and Family Study were followed up 10 to 14 years after initial assessment. Two inclusion criteria were applied: at least one of the parents should have been hospitalized for a functional psychiatric disorder before initial assessment and the male index offspring should be 18 years or older at follow-up. Family communication was observed by the Consensus Rorschach procedure and coded with the Confirmation-Disconfirmation Coding System. Offspring childhood social competence was rated by peers, teachers and parents. Outcome measures included the Denver Community Mental Health Questionnaire, the Global Assessment Scale and hospitalization for a psychiatric disorder. Results showed that the family's level of confirmation and disconfirmation communication during Consensus Rorschach at initial testing predicted offspring interpersonal functioning and hospitalization for psychiatric disorders. These findings were not due to the initial social competence or IQ of the child, the level of functional impairment in parents or their social class.

Adoption studies of schizophrenia.

The understanding and treatment of schizophrenia have been greatly hampered by uncertainty about etiological factors and controversy about diagnostic boundaries. Adoption studies have helped clarify both of these problems. First, the adoptees study method, the index offspring of adopting-away schizophrenic biological parents are compared with control adoptees whose adopting-away parents were non-schizophrenic. Earlier studies have found increased illness in the index adoptees, thus supporting a genetic hypothesis. Additionally, in this approach the comparison of index versus control adoptive rearing families permits the assessment of environmental joint or interaction effects. An on-going Finnish study appears to provide evidence supporting both genetic and environmental main effects, as well as joint effects. Secondly, in the adoptees' relatives method, the biological relatives of schizophrenic index adoptees are compared with the biological relatives of non-schizophrenic control adoptees. A Danish study found that the relatives not only have more frequent typical, narrowly defined schizophrenia but also have more 'latent', non-psychotic forms of the illness. Thus, the adoption studies of schizophrenia are proving valuable in establishing the significance of both genetic and environmental contributions to the illness and in clarifying the diagnostic criteria for a genetically relevant syndrome.

The Finnish adoptive family study of schizophrenia. Implications for family research.

A nationwide Finnish sample of schizophrenics' offspring given up for adoption was compared blindly with matched controls, who were adopted offspring of non-schizophrenic biological parents. The adoptive families were investigated thoroughly using joint and individual interviews and psychological tests. The biological parents were also interviewed and tested. Among the 155 index offspring, the percentage of both psychoses and other severe diagnoses (borderline syndrome and severe personality disorders) was significantly higher than in the 186 matched control adoptees. This supports a genetic hypothesis. However, notable differences between these two groups only emerged in the families which were rated as disturbed. Thus the genetic effect (i.e. the differences between high and low genetic propensity) was only manifested as a psychiatric disorder in the presence of a disturbed family environment. The impact of disturbed family relations was strongest in the presence of the appropriate genotype.

The rationale for consultation with the families of schizophrenic patients.

Mental health professionals have approached families that have a schizophrenic member with four quite different expectations about how the family can aid patient recovery: the family as a source of information; the family as caretaker for the patient; the family as patient stressor, needing family education; and the family as a dysfunctional system requiring family therapy. Overall, professionals have been negligent in attending to the needs of families, seen less for themselves than as agents to aid patient recovery. As an alternative or supplement to family self-help groups, a family consultation model provides professionals with an orientation for working collaboratively with diverse families in their efforts to cope with serious mental illness.

Disqualifying family communication and anxiety in offspring at risk for psychopathology.

The association between disqualifications in parental and family communication and manifest anxiety in boys (7 or 10 years) was investigated. The sample consisted of 59 families where one of the parents had previously been hospitalized for a functional mental disorder. Parental and family communication was observed in the Couples Rorschach (CR) and Family Rorschach (FR) tasks, respectively. The results showed that the amount of one particular type of disqualification, self-disqualification, correlated positively with the boy's anxiety level. Self-disqualification refers to utterances in which the speaker communicates in vague, egocentric or paradoxical ways, which makes it impossible for the receiver to know what has been said. This correlation was evident both with respect to the communication between the parents during CR and the communication from the family to the index boy during FR. The relationship between self-disqualification and anxiety was attributable to neither the boy's age or intelligence quotient nor the dimensions of parental psychopathology or functional impairment.

Competence in children at risk for psychopathology predicted from confirmatory and disconfirmatory family communication.

The relationship between confirmation/disconfirmation in parental and family communication and offspring social competence was examined in 59 families in which at least one of the parents had been hospitalized for a functional psychiatric disorder. Communication samples were obtained using the Consensus Rorschach procedure both with parental couples and with parent-child family units. The communication was analyzed using the Confirmation-Disconfirmation Coding System (CONDIS). The competence at school of 7-and 10-year-old boys was rated by both peers and teachers. Competence at home was rated by the parents. The results indicated that the more competent the high-risk children were, both at school and at home, the more their family communicated in confirmatory ways and the less they communicated in disconfirmatory ways. Furthermore, although the parental couple CONDIS score and the family CONDIS score were modestly correlated, each contributed separately to the prediction of offspring competence. These communication data were not significantly related to parental psychopathology, neither severity of parental impairment nor the diagnosis of the patient-parent.

Illness, family theory, and family therapy: I. Conceptual issues.

This article examines and clarifies controversies about the concept of illness in the field of family therapy. We contend that illness, as traditionally understood in all cultures, is a relational, transactional concept that is highly congruent with core principles of present-day family theories. Family therapists need not buy into a biotechnical, reductionistic reframing of illness as disease. Rather, it is more appropriate to conceptualize and work with illness as a narrative placed in a biopsychosocial context. Such a narrative includes how shared responsibility for coping and for finding solutions can take place, without becoming involved in disputes about causal models.

On the expression of psychosis in different cultures: schizophrenia in an Indian and in a Nigerian community.

This sub-study of the WHO Determinants of Outcome of Severe Mental Disorders research project was aimed at characterizing the behavioral and expressive qualities of schizophrenia in two highly diverse cultures. Early research has indicated that the core elements involving affect, perceptual and cognitive dysfunction in schizophrenia are highly similar in form in most cultures of the world. Much of the cross-cultural literature emphasizes, however, strong differences in the ways in which schizophrenia is actually expressed and manifested in different settings. The basic methodology for psychiatric description and diagnosis in the WHO program was the Present State Examination. In five of the field centers a method for investigating the expressive quality and the social behavior of patients in their own communities through the eyes of significant others was applied. This method was then subjected to psychometric tests of cross-cultural applicability and found to be valid for comparing behavior across settings. The expressive patterns of the Indian and Nigerian patients were studied from two perspectives. Indian schizophrenics were described by family members as manifesting a more affective and "self-centered" orientation; the Nigerian patients presented with a highly suspicious, bizarre, anxious quality to the basic behavioral pattern. The main features of pathology were in general accord with the descriptions of indigenous psychiatrists. The special qualities of the psychosis in the two cultures were interpreted against the background of traditional psychopathological and anthropologic theories concerning the psychodynamics and the influence of differing social conflictual themes in the two cultures. Analysis of psychopathology in this manner was found to enhance understanding of underlying mechanisms and the role of cultural conflicts in its expression.

The prediction of relapse of schizophrenic patients using emotional data obtained from their relatives.

The capacity of anxiety and hostility outward scores derived from the content analysis of 5-minute speech samples from the relatives of patients to predict relapse or nonrelapse was tested in three distinct groups of schizophrenic patients. Significantly correct predictions were made which compared favorably to the predictive capacity of ratings obtained by means of the Camberwell Family Interview. The latter requires 1 to 2 hours to administer and about 1 hour to score, whereas the former method requires a tape-recorded 5-minute speech sample and up to 0.5 hour to score.

The natural histories of schizophrenic processes.

The natural history of schizophrenia cannot be studied directly, but nevertheless can be inferred and conceptualized as a frame of reference for examining the heterogeneity of the syndrome and for evaluating the impact of treatment, environment, and other factors influencing its course. Alternative diagnostic systems, including DSM-III, imply differing, largely unscrutinized concepts of the natural history and have generated skewed samples and noncomparable longitudinal data. The suggestion is made that sounder future research on the course of schizophrenia will focus upon component processes clustered, for example, in the enduring deficit syndrome.