Emotional overinvolvement in parents of patients with schizophrenia or related psychosis: demographic and clinical predictors.
H Bentsen, B Boye, O G Munkvold, T H Notland, A B Lersbryggen, K H Oskarsson, I Ulstein, G Uren, H BjÖÕrge, R Berg-Larsen, O Lingjaerde and U F Malt BJP 1996, 169:622-630. Access the most recent version at DOI: 10.1192/bjp.169.5.622
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British Journalof Psychiatry (1996), 169, 622—630
Emotional Overinvolvement in Parents of Patients with Schizophrenia or Related Psychosis: Demographic
and Clinical Predictors
HAVARDBENTSEN, BIRGITTE BOVE,OLEGEORGMUNKVOLD,TOR HELGENOTLAND, ANNETTEB.LERSBRYGGEN, KIRSTIH.OSKARSSON, INGUNULSTEIN,GUNVORUREN, HEIDIBJØRGE, ROLFBERG-LARSEN, ODDLINGJ@@.RDE andULRIKF.MALT Background.Parental emotional overinvolvement (EOI)mayentaila worseoutcomeinschizo phrenia.Inthepresentstudywe examined demographic andclinicalpredictors of EOl. Method.The predictors were examinedin a Norwegian sample of 41recently admitted patients (schizophrenia
or schizophreniform
disorder) and 66 parents. Parents'expressed
emotion was
assessedby the CamberwellFamilyInterview. Results. Regressionanalyses showed that higherEOlwas significantlyrelated,on the partof theparent,tobeingamother,single,spending moretimewiththepatient@and,onthepartofthe patient,to no substancemisuse,moreanxiety—depression, and lessuncriticalandaggressive behaviour.EOlwas not linkedto previoushospitaladmissions. Conclusion. Ouranalysesindicatethat characteristicsof the parentandof the parent—patient dyadseemtobethemostimportantdetemiinants ofEOLEOIisprobablynotlinkedtopsychotic relapse,but ratherto affectivedisturbancesinthe patient.
Parental overprotection
has long been thought of as
influences (Pérusseet a!, 1994). In the present paper
a risk factor for psychiatric disorders (Levy, 1943; Parker, 1983). In a number of studies, most using retrospective questionnaires, it has been found to predict affective and personality
disturbances
(e.g.
Gotlib et a!, 1988; Bornstein, 1992). In his pioneering empirical study, Levy (1943) charac tensed maternal overprotection by (a) excessive contact, (b) infantilisation, (c) prevention of independent behaviour, and (d) either lack or excess of maternal
control.
This
heterogeneous
definition has led to a lack of conceptual clarity and different research traditions (Thomasgard & Metz, 1993). Yet it reflects that overprotection can shift from being indulgent to being dominating. In the expressed emotion (EE) tradition, overprotec tion is called emotional overinvolvement (EOI), and may be indulgent, dominating or both (Brown et a!, 1972; Leff& Vaughn, 1985). In order to influence such family relationships it is important to know what determines EOI. Until the past 15 years the evidence for aetiological factors was mostly casuistic and theoretical. Since then, statistically-based studies have appeared, implicating trait anxiety (Parker & Lipscombe, 1981), attachment styles (Diamond & Doane, 1994), and both environmental and genetic
we will focus upon demographic and clinical predictors of parental EOI in families having a patient with schizophrenia or related psychosis. Our hypotheses (Table 1) are derived both from the general literature on overprotection and from studies on EE. Method Subjects We included all patients admitted consecutively to two psychiatric hospitals, who, at the time of inclusion, had a diagnosis of schizophrenia or schizophreniform disorder according to DSM—flI R, were admitted during the last week because of an acute episode or relapse, were 18—39 years old, and had had at least weekly face-to-face contact with relatives during the previous three months. We also required that the eligible relatives should be willing
and able to participate in the Camberwell Family Interview (CR; Vaughn & Leff, 1976). The one or two relatives (spouse, cohabitee, sibling, parents, step-parents) with most face-to face contact with the patient were included. All patients were screened by two experienced psychiatrists.
622
The DSM-Ill-R
diagnosis (American
PREDICTORS OF PARENTS' EMOTIONAL OVERINVOLVEMENT Table1 Hypotheses Moreemotionaloverinvohementtowardsthepatientishnkedto: Therelativebeinga mother The patientbeinga male
Thepatienthavingneverbeenin paidemployment Poorerpremorbidfunctioningof the patient
ThepatientlMngwithkeyrelatives One-parenthouseholds Moreface-to-facecontactduringthethreemonthsbeforeadrrvssion
Longertime sincedebutofiliness
Moreprevious admissionsto hospital Substancemisuseduringthe precedingsixmonths
Moredisturbed behaviourdunng thepreceding monthasreported bya keyrelative;in particularmorepassive,depressiveandaggressive behaviours Moresymptomsafteradmissionasassessedbyan investigatorin particular,negative,anxiety-depressive, hostileandcognitive symptoms
623
criticism, hostility and warmth: ‘¿relative socio demography' (mother/father, socioeconomic sta tus), ‘¿family relationship' (patient living with relative, number of people in the household, number of parents in the household, hours of face-to-face (sex, paid
contact), ‘¿patientsociodemography' employment, pnemorbid functioning
(Goldstein, 1978)), ‘¿long-term illness history' (dura tion since debut, time since last discharge, number of previous admissions), ‘¿recent illness history' (preceding three months: number of out-patient consultations, family sessions, neuroleptics before admission; substance misuse in the past six months), ‘¿PerceivedFamily Burden Scale (PFBS) —¿ groups of items' (see Table 2; Levene, 1991), ‘¿PFBS-total', ‘¿Positive and Negative Syn drome Scale' (negative, positive, hostility, depres sive, cognitive components; Kay & Sevy, 1990), and ‘¿Clinical Global Impression' (Guy, 1976). Details will be reported
elsewhere
(Bentsen
et a!, sub
mitted). Psychiatric Association, 1987) made at inclusion was reassessed one year later, but all patients were kept in the study. All investigators were extensively trained, and tested with regard to inter-rater reliability (Bentsen et a!, 1996a,b, in press). In this part of the study only patients (n = 41) and parents (n = 66) were included. The parental subgroup was chosen mainly because of the easier interpretation of results and better correspondence with the parental overprotection literature. Ten (20%) of the eligible patients were not included. In 39 households all eligible relatives participated. @ Predictor variables Logically related variables were grouped in chunks
(Kleinbaum et a!, 1988). We used the same chunks and predictor variables as in our studies on
Outcome variable Relatives' EOI towards the patient was determined on the basis of the abbreviated version of the CR. Ratings of audiotaped interviews were performed according to standard criteria (Leff & Vaughn, 1985). EOI is measured on a six-point global scale (0= none, 5= marked), and is rated on the basis of reported behaviour
of the respondent
(exaggerated
emotional response, self-sacrificing and devoted behaviour, and extremely overprotective behaviour) and the behaviour of the respondent at the interview (statements of attitude, emotional display, dramatisation). High EOI has been defined as EOI 3 (most studies before 1986) or EOI @4 (all studies before 1986). If not otherwise stated, the former threshold will be used in the present study. All raters were approved by the Institute of Psychiatry, London, as reliable raters for the subscales of critical comments, hostility, emotional
Table2 PerceivedFanily BurdenScale:patientbehaviourduringthemonthbeforeadmission VariableItemsAnxiety-depression
Uncritical behaviour Passivity
Aggression Drugs Total AllGrouping PFBSLooks
fearful,lookssad,mopes,threatenssuicide,actssuspicious,self-harm Talksloudly@ yells,talksnonsense,laughsfrequently,usesabusivelanguage,paces
Staysinbed,hardlytalks, looksmessy Refuses medication, refuses help,threatens violence, throwsthings, harasses others,blames others Misuses drugssmokes, refuses food
of Itemsby Benteenet@(subn@tted).Measureof items O=absent,1=present. Measureof variables mean of constituent items (0-tOO).
624
BENTSEN
overinvolvement, and the EE index. In the present study, all audiotaped interviews were rated by two independent raters. The inter-rater reliability of EOI was, for the six-point scale intra-class correla tion coefficient (ICC; random effect model, REML), 0.65, the binary scale (high EOI?3) 0.51, and the binary scale (high EOI@4) 0.46 (Bentsen et a!, 1996a). The two raters then made a consensus score. If they could not reach this, all approved raters discussed the unclear issues and made a final group decision.
Statistical analyses
@
ET AL
‘¿duration of neuroleptic treatment after admission'. Throughout
the
study
the
required
level
of
significance was
[email protected]. All statistical SPSSIPC+4.O
analyses were done by means of
(Norusis,
1990),
except
for
general
mixed-model analysis of variance (ICC(REML)), Fisher's exact test, and logistic regression, which were done by means of 1BMDP, version 7.0, programs 3V, 4F and LR, respectively (Dixon, 1992).
Results
The association between EOI, treated as continuous Sample characteristics or binary scales, and the predictor variables was Sociodemographically, the patient sample was analysed by bivariate tests (simple linear or logistic mainly young (27.9 years, s.d. 6.5), male (63%), regression, respectively) and forced-entry multiple living at home with family members (71%), having regression analyses (linear or logistic, respectively) been at some time in paid employment (59% (Kleinbaum et a!, 1988; Hosmer & Lemeshow, previously only, 27% currently), less than half 1989). The effect of each predictor variable in a having a chronic social security status (39%). chunk was adjusted for by the other variables in Clinically, 30 (73%) fulfilled DSM-Ill-R criteria that chunk and a set of control variables (“full of schizophrenia one year after inclusion, six had a model―).This set consisted of characteristics of the schizoaffective disorder, two a schizophreniform patient, the relative, and their relationship that, a disorder, and three had other psychoses; 37% of the priori, were thought to be potential important effect patients were admitted for the first time. The modifiers or confounders: ‘¿kind of relative', ‘¿socio median time since debut of illness was four years economic status' (relative), ‘¿sex of patient', ‘¿dura(range 0.1—20).The most frequent deviant beha tion since debut of illness', ‘¿face-to-face contact' viours reported by relatives were related to anxiety and each of the five Positive and Negative and depression (on average, three of six such Syndrome Scale (PANSS; Kay et a!, 1987) behaviours per patient). The mean CGI score components (except for the chunks Clinical Global indicated moderate illness (4.5, range 3-7). Of the Impression (CGI) and PFBS). 10 (24%) patients that had used street drugs or In the logistic regression analyses, statistical benzodiazepines illicitly, eight had used cannabis, significance was assessed by the maximum like several of these less than twice a week. lihood method. The predictive contribution of each In the parental sample, 56% were mothers (one a chunk, with and without adjustment for the set of stepmother) and 44% were fathers (two step control variables, was tested by multiple partial F fathers); 79% were living as married couples; and tests (linear regression) or likelihood ratio tests 70% were living with the patient. Face-to-face (logistic regression). Goodness-of-fit of the full contact during the preceding three months was on model was assessed by residual plots (linear average 25 hours per week (median 18 hours). Both regression) or the Hosmer—Lemeshowstatistic C lower and higher socioeconomic classes were well (logistic regression). represented. The mean EOI was 2.2 (0-5). For 32 The significance of first-order interaction effects (49%) parents EOI was 3, and for 10 (15%) was tested in the full models. Variables were tested EOI ?4. Nine (14%) parents were rated as both for all plausible interactions with other variables in highly overinvolved and critical. the chunk. All variables were tested for interactions More details pertaining to sample characteristics with ‘¿kind of relative' and ‘¿face-to-face contact'. are available from the author on request. ‘¿Paid employment', ‘¿sex of patient', ‘¿substance misuse', PANSS, CGI and PFBS were tested for interactions with ‘¿living with relatives'. ‘¿Number of previous hospital admissions', PANSS, CGI and Associations between parents' EOI and predictor variables PFBS were tested for interaction with ‘¿duration since debut of illness', and PANSS and CGI with The main results are shown in Tables 3 and 4.
PREDICTORS OF PARENTS' EMOTIONAL OVERINVOLVEMENT Re!atives' sociodemographic variab!es This chunk was related to EOI ‘¿continuous' (R2 of the full model= 0.36). Residual analysis indicated that the model seems to fit the data well. The relationship
with high EOI was nearly significant.
Being a mother was highly significantly linked to being more overinvolved. Family re!ationship
@
This chunk was related to EOI continuous (R2 of the full model= 0.40) and EOI ?4 (adjusted: P 3, and the pattern seems to resemble
a struggle
for power between
parent and offspring. The interaction between passivity and contact means that when contact was low, overinvolvement was non-significantly related to more passivity, whereas EOI was significantly linked to less passivity when contact was high. For instance, in the first case, EOI continuous, adjusted for demographic control variables, predicted ‘¿stays in bed' (adj. OR= 2.76, P=0.04), whereas in the latter case, EOI predicted the absence of such behaviour (adj. OR =0.06, P=0.000l). This suggests that, when contact is high, the patient is more obedient, and higher EOI is more effective in controlling the patient; when contact is low, the patient is more defiant, and higher EOI seems to have a negative effect. As in most other studieson thisissue(e.g.
Vaughn et a!, 1984; Mueser et a!, 1993) we did not find any significant association between EOI and symptoms assessed by a researcher. The only exception was that, for the subgroup of recent onset patients, EOI ? 3 was linked to fewer negative symptoms. Perhaps this can be explained in the same way as passivity of high-contact patients. In general, the discrepancy of PFBS and PANSS data, also found for criticism and hostility (Bentsen et a!, submitted), probably indicates that the behaviouris highlydependent on who observes
and in what context. No association with previous hospital admissions This finding is, to the extent that admission reflects psychotic exacerbation, consistent with the bulk of evidence from follow-up studies: EOI does not seem to be a predictor of psychotic relapse (and it should therefore be expelled from the EE index). Of 21 anglophone follow-up studies (Bebbington & Kuipers, 1994), only nine report data on the link between EOI and psychotic relapse. This link was significant in only two of the studies (Moline et a!, 1985; Ivanovic et a!, 1994).
Comments Although almost all tapes were rated by two raters and the final scoring was reached by consensus, the moderate inter-rater reliability will entail some attenuation of correlations (Bentsen et a!, l996a).
PREDICTORS
@
OF PARENTS'
EMOTIONAL
Several strong links and mostly acceptable fitting of models indicates that this has not been a major problem. The links of passive (or negative symptoms) behaviour may have been somewhat underesti mated because such items are poorly represented in the PFBS. The number of tested variables was relatively large in relation to the sample size. In general, goodness-of-fit tests indicated that this was not problematical. We tested 56 main-effect associations between predictor variables and EOI continuous/EOI 3; 24 links were significant at
[email protected]. We did not correct for multiple testing (Altman, 1991), because we considered the risk of type H errors, missing potential determinants of EOI, as more serious than type I errors. If we had applied a Bonferroni correction the level of significance for the links between predictor variables and EOI would be 0.05/
[email protected] significant or nearly significant links would then have been those between face-to-face contact and EOI continuous (mothers, P=0.0001), between patient anxiety-depression and high EOI (P=0.0009), (P=0.003).
629
OVERINVOLVEMENT
ChnicalImplications •¿ Parents living alone with the patient are a risk group for high EOI (@4) and are probably in parti
cularneed of support •¿ Patients' anxious-depressive behaviour, not ob served by the professional but only by the over
involved parent, may be part of a vicious circle,
andshouldbe targetedinfamilywork •¿ EOlis probablynot linkedto psychoticrelapse, but to affectivedisturbancesinthe patient Limitations
•¿ Ignoring clustering of data (two relatives/one patient) may have contributed
to underestimation
of links.No correctionfor multipletesting may have led to too many ‘¿false positive' results. •¿ The sample size is small in comparison to the
numberoftestedvariables.This mayhavecontrib utedto modelsbeingmoreunstable. •¿ The correlational nature of the study entails un certainty about the extent to which predictors
are causes or effectsof EOL
and between aggression and high EOI
In statistical analyses, the relatives were con sidered as independent of each other, although 50 of the 66 were couples. By ignoring matching, we may have underestimated links (Neuhaus, 1992). The correlational nature of the study means that, for some predictor variables, the issue of cause or effect cannot be settled with certainty (i.e. PFBS anxiety—depression), whereas for others (mother, face-to-face contact, single parent and, to some extent, drug misuse and aggression) the causal direction seems to be unambiguous. Determinants of EOI might differ according to the level of warmth and criticism, i.e. there might be interaction effects. We have not included these EE factors in our predictor models to avoid instability. Other determinants of EOI related to relatives' personality (guilt-proneness, locus of control) will be discussed in subsequent papers. In conclusion, our analyses indicate that characteristics of the parent and of the parent patient dyad seem to be the most important determinants of EOI. Low levels of EOI were linked to an externalising patient coping style, whereas high levels were linked to an internalising coping style. To the extent that high EOI may be harmful for the patient, especially by reinforcing dependency and depression, family intervention seems to be the treatment of choice (Levy, 1943; Leff, 1994).
Admow@ments This work was performed as part of the first author's tenure of research fellowships provided by the Research Council of Norway, Programme for Mental Health, C373.90/012, the Norwegian Council for Mental Health, 940037/8, and Gaustad Hospital, Oslo. The research was supported by grants from Josef and Haldis Andresen's Legacy. Additional financial support was provided by the Odd-Fellow Research Foundation, Anders Jahre's Foundation
and legacies administered by the University of Oslo (Hans Evensen's Legacy, Eilertsen's Legacy, Christiansen's Legacy). We thank Anders Skrondal for invaluable statistical advice.
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Hivard Bentsen, MD, Department Group of Psychiatry, University of Oslo, and Gaustad Hospital, Oslo, Norway; Birgitte Boye, MD, Ole Georg Munkvold, MD, Tor Helge Notland, MD, Annette B. Lersbryggen, MSW, Kirsti
H. Oskarsson,
MD, Blakstad
Hospital,
Asker;
Ingun
Ulsteln,
MD, Gaustad
Hospital,
Oslo,
Norway; Gunvor Uren, san, Blakstad Hospital, Asker; Helde B@rge, SRN,Gaustad Hospital, Oslo; Roif Berg-Larsen, MD, Blakstad Hospital, Asker; Odd Llngjairde, MD, Department Group of Psychiatry, University of Oslo, and Gaustad Hospital, Oslo, Norway; UlrIk F. Malt, MD, Department Group of Psychiatry, University of Oslo Correspondence: Dr H. Bentsen,P0 Box 33, Gaustad,N-0320Oslo,Norway (First received 15 December 1995,final
revision 23 May 1996, accepted 18 June 1996)
