2008, Number 3
Relación entre la emoción expresada por el familiar responsable y la conducta sintomática de pacientes con esquizofrenia, incluido el funcionamiento social
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ABSTRACTIn the 1950’s, several authors carried out a series of studies focusing on the course of schizophrenia rather than its etiology. They found a link between the living conditions to which patients returned after being discharged from the hospital, and their risk of relapse. A higher risk was observed in those patients that returned to their conjugal or parental home, compared to those who returned to other living conditions. This line of work that explored stressful family mechanisms coined a term known as expressed emotion (EE) —high and low— in the family, which refers to the evaluation of the quantity and quality of attitudes and feelings such as criticism, hostility and overinvolvement of a family member towards the person diagnosed with schizophrenia. These attitudes among family members have been associated with the presence of relapse in patients two years after being discharged from the hospital when family members and the patient live in the same household and are in contact 35 hours or more per week.
It has been proved that these attitudes exert an influence, either increasing or decreasing the exacerbation of symptoms and, in some cases, leading to the patient’s rehospitalization. Higher rates of relapse (92%) have been found in patients that spend over 35 hours a week with the relative in charge (RIC) and were not taking antipsychotic medication.
It has also been found that when a RIC with high EE is in close contact with the patient, the latter is at risk of experiencing a symptom exacerbation that increases two to four times the probability of relapse.
The most typical emotional expressions are critical comments, hostility, and excessive affective involvement. Criticism and overinvolvement are usually perceived as stressful. Criticism implies intolerance and disapproval, whereas over-involvement suggests intrusiveness and control, and includes high levels of anxiety in the patient. Some positive aspects are also found, like the demonstration of warm feelings.
a) Criticism. Includes comments and statements which due to the way that are expressed by the RIC represent unfavorable comments about the behavior or personality of the individual being referred to. In other words, it shows aversion or disapproval of a person’s behavior or characteristics.
b) Over-involvement. More commonly found in parents than in other relatives, it includes over-protection or consent, self-sacrifice and emotional distress. The patient is regarded as less competent and more vulnerable.
c) Hostility. Generally occurs when there is criticism, which is why it is of little value as an independent predictor. Hostility occurs when the patient is attacked for what he is, rather than for what he does.
The main objective of this article is to show the relationship between the level of expressed emotion (EE) (high or low) of the relative in charge with symptomatic behavior (SB) and social functioning (SF) of the patient with schizophrenia. It also includes a proposal of a conceptual model to evaluate the predictive factors of high EE.
A transversal non-probabilistic study of 33 relatives of patients with schizophrenia was carried out. The relatives were contacted through the Schizophrenia Clinic in the outpatient unit at the hospital of The National Institute of Psychiatry Ramón de la Fuente in Mexico City.
The instruments used were: 1. The Social Behavior Assessment Schedule (SBAS) and 2. The Questionaire for Measuring the Level of Expressed Emotion (Cuestionario-encuesta, evaluación del nivel de EE [CEEE]).
The results indicated that 14 (42.4%) of the interviewed relatives had high EE and 19 (57.6%) had low EE. The main characteristics associated with high EE in RIC were: living in the same household with the patient’s mean age of 54.8 years, having less than 12 years of education, being employed and not having a spouse.
The most frequent expressed emotions were criticism, hostility and over-involvement. In patients, the main characteristics were: being male, young, with a mean age of 29.2 years, single and without employment alternatives, with two or more relapses and with a diagnosis of schizophrenia for five or more years.
The presence of symptoms in the patient’s according to relatives with low EE was 31.6% as opposed to 74.1% reported by RIC with high EE.
Relatives with high EE mentioned greater personal neglect, irritability, violent behavior and isolation on the part of the patient, whereas relatives with low EE reported more fears, forgetfulness, dependence and strange ideas as problematic behaviors in the patients. The differences found between relatives with high and low EE regarding the patients’ functioning were clearly demonstrated. Relatives with low EE reported better functioning in patients’ performance of chores, demonstration of affect, involvement in leisure activities and better communication skills.
Relatives with low EE reported that the persistence of the symptoms in their patients was 31.6%, whereas for those with high EE it was 71.4%.
A logistic regression was used to identify the best predictors of EE, where the dependent variable was the total EE score, and the predictors were the continuous variables for social functioning and symptomatic behavior. A significant association was found between the two variables. Poor social functioning, symptomatic instability in the patient and being the patient’s sibling explained 46% of the variance in RIC with high EE. The predictors had high levels of statistical significance.
The model revealed the independent contribution of each variable and its interaction with the others. The level of family EE can be considered as the best predictor of relapse in patients with schizophrenia. Thus, EE acquires a special relevance: when high EE causes relapse, the reduction of the level of EE will lead to a decrease in relapse rates. Although the traditional means of measuring EE through the CFI has been found to be highly effective, it takes a long time to apply and classify the answers of the instrument. Another alternative is the CEEE that has been used in this study, since it has been used in other clinical trials due to the brief time required for training, application and classification of the data.
Linszen DH, Dingemans PM, Scholte WF, Lenior ME: Expressed emotion en patientgebonden kenmerken als riscofactoren voor psychoserecidief bij schizofrene stoornissen. Expressed emotion and patients’ artributtes as risk factors for psychotic relapse in schizophrenic disorders. Tjdschrift-voor Psychiatrie 1994;36(7):495-508.
Guanilo JV, Seclén YM. Relación entre el nivel de conocimientos sobre enfermedad mental y el nivel de emoción expresada de los familiares de pacientes esquizofrénicos de consultorios externos del INSM HDHN. Tesis para obtener el título profesional de enfermera, Universidad Nacional Mayor de San Marcos, Facultad de Medicina. Lima, Perú, 1993.