Psychiatry Research 110 (2002) 273–280

Family attitude scale: measurement of criticism in the relatives of

patients with schizophrenia in Japan
Hirokazu Fujitaa,e,*, Shinji Shimoderaa, Yuji Izumotoa, Shuichi Tanakab,f, Masaru Kiic,g,
Yoshio Minod,h, Shimpei Inouea
a
Department of Neuropsychiatry, Kochi Medical School, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505, Japan
b
Watarigawa Hospital, Gudo, Nakamura, Kochi, 787-0019, Japan
c
Tosa Hospital, Shin-honmachi, Kochi, 780-0062, Japan
d
Department of Hygiene and Preventive Medicine, Okayama University Medical School, 2-5-1, Shikata-cho, Okayama, 700-8558,
Japan
e
Ichiyo Mental Hospital, 9-3, Akasaki-cho, Susaki, Kochi, 785-0037, Japan
f
Maaruikokoro Clinic, 6775-1, Gudo, Nakamura, Kochi, 787-0019, Japan
g
Department of Neuropsychiatry, Hata Prefectual Hospital, 3-1, Yoshina, Yamana-cho, Sukumo, Kochi, 787-0785, Japan
h
Department of Mental Health, College of Social Welfare, Osaka Prefecture University, 1-1, Gakuen-cho, Sakai, Osaka, 599-8531,
Japan

Received 22 September 2000; received in revised form 20 April 2001; accepted 8 May 2001

Abstract

Expressed emotion (EE) is traditionally measured with the Camberwell Family Interview (CFI), but the CFI
requires considerable time for both execution and evaluation. As an alternative, we investigated the validity of the
Family Attitude Scale (FAS), a questionnaire developed for the measurement of EE. The CFI, the FAS, the General
Health Questionnaire (GHQ), and the Five-Minute Speech Sample (FMSS) were administered in 57 members of the
families of 41 patients with acute episodes of schizophrenia. The relative sensitivity and specificity of EE assessment
with the FAS compared with the criticism component of the CFI were 100% and 88.5%, respectively. EE assessment
based on criticism as assessed with the FMSS compared with the CFI had a sensitivity of 40.0% and a specificity of
90.4%. The GHQ score tended to be higher in the high-scoring FAS group than in the low-scoring FAS group. The
FAS showed excellent validity for the measurement of critical aspects of family attitudes, and the FAS score reflected
the state of psychological health of the families. 䊚 2002 Elsevier Science Ireland Ltd. All rights reserved.

Keywords: Schizophrenia; Expressed emotion (EE); Camberwell Family Interview; Five-Minute Speech Sample; General Health
Questionnaire

1. Introduction with schizophrenia (Vaughn and Leff, 1976; Leff

Studies on expressed emotion (EE) have been
primarily conducted in the families of patients
*Corresponding author. Fax: q81-88-880-2360.
E-mail address: fujitah@med.kochi-ms.ac.jp (H. Fujita).
and Vaughn, 1985) or mood disorders (Hooley et
al., 1986). Especially with regard to schizophrenia,
the measurement of EE in family members has
attracted attention as a possible predictive factor
of symptomatic relapse (Bebbington and Kuipers,

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 1 0 8 - 7
274 H. Fujita et al. / Psychiatry Research 110 (2002) 273–280
1994). Psychoeducational training for families has
reduced the relapse rate for schizophrenic patients
from high-EE environments (Falloon et al., 1982;
Leff et al., 1982; Shimodera et al., 2000a). High
EE has also been associated with poorer social
functioning (Barrowclough and Tarrier, 1990;
Inoue et al., 1997) and negative or depressive
symptoms (Mino et al., 1998) in patients with
schizophrenia
The Camberwell Family Interview (CFI; Leff
and Vaughn, 1985; Vaughn and Leff, 1976), which
is the standard interview method for the assessment
of EE, requires 60–90 min to administer, and
analysis of its results takes even longer. Therefore,
the routine clinical use of the CFI is not feasible.
To overcome this problem, several alternative
measures of EE have been developed. The duration
of the interview is shortened in the Five-Minute
Speech Sample (FMSS; Magana ˜ et al., 1986), and
the validity of EE assessment using this method
has been established (Malla et al., 1991; Shimo-
dera et al., 1999). However, EE assessment with
the FMSS may not be significantly correlated with
schizophrenic relapse (Thompson et al., 1995;
Uehara et al., 1997). Self-report measures used to
evaluate the home environment of patients with
schizophrenia include the Influential Relationships
Questionnaire (IRQ; Baker et al., 1984) and the
Parental Bonding Instrument (PBI; Parker et al.,
1979). The Level of Expressed Emotion (LEE;
Kazarian et al., 1990) is an attempt to measure EE
in patients using a self-report measure, and it has
been reported to predict symptomatic improvement
in depressed outpatients (Gerlsma and Hale, 1997).
Another potentially useful measure is the Family
Attitude Scale (FAS; Kavanagh et al., 1997), in
which emphasis is placed on the EE dimensions
of criticism and hostility. The FAS is a self-report
measure that can be used by family members of
patients with schizophrenia and contains a relative-
ly small number of questions (30). In the current
study, we administered a Japanese translation of
the FAS to the family members of patients with
schizophrenia and compared EE assessment by
this method with assessment by the CFI. The
sensitivity and specificity of the FAS relative to
the CFI, as well as its positive predictive value
(PPV) and negative predictive value (NPV), were
also compared with those for the FMSS. Because
the level of EE has been reported to be related to
the distress of family members themselves (Bar-
rowclough and Parle, 1997; Shimodera et al.,
2000b), we compared it with the Japanese version
of the General Health Questionnaire (GHQ; Gold-
berg and Williams, 1988; Nakagawa and Daibo,
1985).
2. Methods
2.1. Assessment instruments
Family distress was assessed with the Japanese
versions of the GHQ-60 and four subscales (phys-
ical symptoms, anxietyyinsomnia, social dysfunc-
tion, and depression) (Nakagawa and Daibo,
1985). We compared the average GHQ score
between the high-EE and low-EE groups as
defined by the FAS.
Psychiatrists who were unaware of the family
members’ EE status and GHQ scores used the
Japanese versions of the Brief Psychiatric Rating
Scale (BPRS; Overall and Gorham, 1962; Koka-
kowska, 1976) and the Scale for the Assessment
of Negative Symptoms (SANS; Andreasen, 1982,
1983) to assess patients’ psychological symptoms.
The association between psychological symptoms
in the patients and the FAS score in their relatives
was also evaluated.
2.2. Reliability assessment
A rater (Y.M.) qualified by the Medical
Research Council Social and Community Psychi-
atry Unit and a rater (S.T.) who showed high
agreement with him (ks0.94). (Mino et al., 1995
performed the CFI assessments. Two raters who
had received formal training by scientists from
UCLA (S.S. and Y.I.) performed the FMSS assess-
ments. A high coefficient of inter-rater reliability
in FMSS assessment was obtained by the two
psychiatrists (ks0.86). To maintain high agree-
ment among the raters for the CFI and FMSS, a
meeting was held once a month. The high coeffi-
cient of inter-rater reliability achieved for the CFI
and the FMSS was maintained over the course of
the study.
 H. Fujita et al. / Psychiatry Research 110 (2002) 273–280
2.3. The FAS
The FAS contains 30 questions (e.g. ‘I wish he
were not here’; ‘He is a real burden’; and ‘He is
hard to get close to’). Respondents reported how
often each statement was true on a scale ranging
from ‘Everyday’ (4) to ‘Never’ (0). Responses
were summed to give a score that ranged from 0
to 120, with higher scores indicating higher levels
of burden or criticism. We translated the FAS into
Japanese, performed back-translation, and con-
firmed that the original FAS agreed with the
translated one.
Kavanagh et al. (1997) originally applied the
FAS for the overall assessment of EE. Because the
assessment of emotional overinvolvement (EOI)
was difficult to make, they ultimately limited its
use to the assessment of the high ‘critical com-
ments’ group (Kavanagh et al., 1997).
2.4. Subjects and study design
Patients with diagnoses of schizophrenia were
selected from consecutive admissions to the
Department of Neuropsychiatry, Kochi Medical
School and the affiliated Tosa Hospital between
June 1, 1998, and November 30, 1999. To be
included in the study, patients had to be between
15 and 65 years old; had to have a discharge
diagnosis of schizophrenia as defined in DSM-IV
(American Psychiatric Association, 1994) andyor
ICD-10 (World Health Organization, 1992); had
to have lived with their relatives for 3 months or
more before admission; and had to be discharged
from the hospital to live with their relatives. The
patients’ parents, their spouses, or other relatives
living with the patients were defined as major
family members. The patients were consecutively
enrolled in this study. The initial number of
patients was 61. Out of these, 43 patients and their
family members consented to enrolment. However,
a member of one family could not complete the
questionnaire, and a member of another family
refused to perform the FMSS. Therefore, 41
patients and their family members constituted the
final sample.
Explanation of the study was given to the
patients by the psychiatrist in charge and to family
275
members by either the psychiatrist or a caseworker.
Written informed consent was obtained from fam-
ily members. The family members were inter-
viewed at home or in the interview rooms of the
hospitals within approximately 2 weeks of the
patient’s admission. First, Japanese versions of the
FAS and the GHQ were administered. On the same
day, the FMSS was performed, and after a rest
period of approximately 10 min, the CFI was
administered. The interview was recorded on tape,
and subsequently transcribed. The level of EE as
determined by the CFI was assessed using the tape
and transcript. CFI and FMSS assessments were
performed independently by two different raters.
In EE assessment by the CFI, the presence of six
or more critical comments (CC), the presence of
hostility, or an EOI score of three or greater was
considered to indicate high EE (Leff and Vaughn,
1985). Family members who did not meet the
foregoing criteria were defined as low EE. A
family was classified as a high-EE family if at
least one family member was assessed as high in
EE. Otherwise, a family was assessed as low in
EE. The family members who were rated as high
EE because of a high score for critical comments
(CC) on the CFI or the FMSS were classified as
a HCC group and the others as a LCC group.
2.5. Data analysis
The cut-off point for high vs. low EE was
established by drawing the Receiver Operating
Characteristics (ROC) curve based on the FAS
score and the results of the CFI concerning HCC.
The sensitivity and the false–positive rate were
calculated for various cut-off FAS scores, and a
cut-off point was determined at the level where
the sensitivity was highest, and the false–positive
rate was lowest.
Statistical analyses were carried out using the
SPSS 10.0 for Windows. Comparisons between
high-EE and low-EE groups, as defined by the
CFI, and high-FAS and low-FAS groups were
based on t-tests and x2-tests.
3. Results
3.1. Characteristics of subjects
There were no significant differences in char-
acteristics such as age, sex, duration of illness,
276 H. Fujita et al. / Psychiatry Research 110 (2002) 273–280

number of previous admissions and proportion of

each diagnostic subtype between the 41 patients
who participated in this study and the 20 who did
not take part. A total of 57 family members
participated in this study: 29 mothers; 22 fathers;
one wife; two husbands; one sister; and two
grandmothers. The mean age of the relatives was
57.9 years old, and 73.3% of relatives were in
face-to-face contact with the patients in excess of
35 h each week.
On the CFI, the families of 12 patients (29.3%)
showed high EE: high CC (4); high EOI (7); and
high CCqEOI (1). The families of 29 patients
(70.7%) showed low EE. No significant demo-
graphic differences were observed between the
high-EE and the low-EE groups defined by the
CFI (Table 1).

3.2. Evaluation of the FAS cut-off point

Mean FAS scores of the high-EE and low-EE
groups and the HCC and LCC groups were com-
pared (in each case, based on CFI assessment).
The FAS scores (mean"S.D.) of the high-EE and
low-EE groups were 52.8"18.5 and 36.1"19.5,
respectively (ts2.739, d.f.s55, Ps0.009). The
score range of the FAS of the high-EE and low-
EE groups was 23–86 and 4–80, respectively. The
FAS scores (mean"S.D.) of the HCC and LCC
groups were 69.6"19.5 and 37.0"18.8, respec-
tively (ts3.800, d.f.s55, Ps0.002). The FAS
score (mean"S.D.) of all the families was
Fig. 1. Evaluation of the cut-off point in FAS by the ROC
curve.
39.9"20.4. Correlations of the subscales of the
CFI with the FAS were as follows (critical com-
ments: rs0.47, Ps0.002; hostility: rs0.37, Ps
0.004; EOI: rs0.08, Ps0.57; warmth: rsy0.39,
Ps0.002).
To determine the cut-off point of the FAS, an
ROC curve was drawn, and the co-ordinates were
determined (Fig. 1). In this curve, the FAS score
at which the sensitivity was highest and the false–

Table 1
Patients’ characteristics in high-EE and low-EE groups as defined by the CFI

High EE Low EE
(ns12) (ns29)
Gender (% males) 50.0 62.1
Age (mean"S.D.) 33.1"9.3 32.9"10.4
Duration of illness (years) (mean"S.D.) 8.1"6.6 10.6"9.2
No. of past hospitalisation (mean"S.D.) 3.3"4.9 3.9"3.7
BPRS (mean"S.D.) 33.1"11.7 29.5"8.2
SANS (mean"S.D.) 53.0"12.6 55.1"22.0
Diagnosis (%)
F20.0 (paranoid) 0.0 17.2
F20.1 (hebephrenic) 66.7 65.5
F20.2 (catatonic) 8.3 6.9
F20.3 (undifferentiated) 25.0 6.9
F25.0 (schizoaffective) 0.0 3.5
 H. Fujita et al. / Psychiatry Research 110 (2002) 273–280
Table 2
Comparison between EE assessments on the FAS and CFI
Overall (CFI)a CFIb
High Low HCC LCC
FAS
High 5 6 5 6
Low 8 38 0 46
a
Sensitivity 5y13s38.5%, specificity 38y44s86.4%, PPV
5y11s45.5%, and NPV 38y46s82.6%.
b
Sensitivity 5y5s100%, specificity 46y52s88.5%, PPV 5y
11s45.5%, and NPV 46y46s100%.
positive rate (1-specificity) was lowest was 60.
Therefore, the cut-off point was set at 60, and a
FAS score of 60 or above was defined as high
FAS and one below 60 as low FAS.
3.3. Evaluation of the validity of the FAS
Table 2 shows the results of the comparison
between EE assessments on the FAS and the CFI.
The sensitivity, specificity, PPV, and NPV for each
are also shown. On the overall evaluation, 13
family members (22.8%) were rated as high EE
and 44 (77.2%) as low EE on the CFI. The
evaluation on the FAS assessed 11 family members
as high FAS (19.3%) and 46 as low FAS (80.7%).
Five of 13 ratings in the high-EE group defined
by the CFI were based on criticism. The sensitivity
and the specificity of the FAS to the CC rated by
the CFI were 100% and 88.5%, respectively. In
our study the performance of the FAS in assessing
overall EE was poor.
Table 3 shows the results of the comparison
between EE assessments on the CFI and the FMSS.
The sensitivity, specificity, PPV, and NPV for each
are also shown. The overall evaluation on the
FMSS assessed 11 family members as high EE
(19.3%) and 46 as low EE (80.7%). Seven of 11
ratings in the high-EE group by the FMSS were
based on criticism. The sensitivity and specificity
of the CC rated by the FMSS to the CC rated by
CFI were 40.0% and 90.4%, respectively. The
sensitivity of the FAS was higher than that of the
FMSS, and the specificity of the FAS and the
FMSS was almost equal. Again, in our study the
performance of the FMSS in assessing overall EE
was poor.
277
3.4. Comparison between the high-FAS and low-
FAS groups
On the FAS evaluation, nine families (22.0%)
were rated as high EE and 32 (78.0%) as low EE.
Comparison of characteristics of patients between
the high-FAS and low-FAS groups revealed no
significant difference (Table 4). Characteristics of
the family members in the high-FAS and low-FAS
groups were also evaluated (Table 5). The GHQ-
60 scores and the scores on the four GHQ-60
subscales tended to be higher in the high-FAS
group, but the differences were significant only for
the items on physical symptoms (ts2.372, d.f.s
55, Ps0.021).
The characteristics of the family members in the
high- and low-EE groups were evaluated in the
same way. There were no significant differences
in the GHQ-60 total score and the four GHQ-60
subscale scores.
4. Discussion
This report is the first study in which the validity
of the FAS was evaluated using sensitivity and
specificity. In the previous report (Kavanagh et al.,
1997), mean FAS scores were compared between
high EE and low EE and correlations between the
subscales of the CFI and the FAS scores were
evaluated. The validity of the FAS was not evalu-
Table 3
Comparison between EE assessments on the CFI and FMSS
Overall (CFI)a
High Low
Overall (FMSS)
High 4 7
Low 9 37
CFIb
HCC LCC
FMSS
HCC 2 5
LCC 3 47
a
Sensitivity 4y13s30.8%, specificity 37y44s84.1%, PPV
4y11s36.4%, and NPV 37y46s80.4%.
b
Sensitivity 2y5s40.0%, specificity 47y52s90.4%, PPV
2y7s28.6%, and NPV 47y50s94.0%.
278 H. Fujita et al. / Psychiatry Research 110 (2002) 273–280

Table 4
Patients’ characteristics in high-FAS and low-FAS groups

High FAS Low FAS

(ns9) (ns32)
Gender (% males) 55.6 59.4
Age (mean"S.D.) 34.2"8.2 32.6"10.5
Duration of illness (years) (mean"S.D.) 8.0"5.8 10.4"8.0
No. of past hospitalisation (mean"S.D.) 3.0"3.3 3.9"4.3
BPRS (mean"S.D.) 32.7"9.0 29.5"9.5
SANS (mean"S.D.) 54.8"20.7 54.4"19.6
Diagnosis (%)
F20.0 (paranoid) 0.0 15.6
F20.1 (hebephrenic) 88.9 59.4
F20.2 (catatonic) 0.0 9.4
F20.3 (undifferentiated) 11.1 12.5
F25.0 (schizoaffective) 0.0 3.1

ated using sensitivity and specificity. The cut-off suggest that the FAS, which is more easily per-
point of the FAS was 50 in the earlier report, with formed than the FMSS, should be the preferred
71% of high-criticism and 62% of low-criticism measure. Since the ultimate test of the FAS, the
environments being defined. In the present study, FMSS and the CFI is predictive validity, outcome
we established the FAS cut-off point on the basis studies should be performed to confirm the clinical
of an ROC curve established by the results of the usefulness of the FAS.
CFI. This approach is often used in the evaluation The PPV was low (45.5%) on the HCC-yLCC-
of the precision of diagnostic and screening tests based CFI evaluation of the FAS in our study. That
and in comparisons of new tests with conventional is, more than half of the cases that were rated as
tests (Fletcher et al., 1996). The FAS cut-off point high with the FAS were rated as low with the CFI.
in this study was higher than that in the earlier Generally, PPV is affected by the morbidity rate;
study (Kavanagh et al., 1997). Similarly, the cut- in the case of low morbidity, PPV is low (Fletcher
off point in the Japanese questionnaire was higher et al., 1996). In this report, the morbidity, regarded
than in the English version of the GHQ (Kitamura as the rate of HCC, was only 8.8% (5y57). This
et al., 1989). However, it may be that some of the low morbidity may explain the low PPV in our
Japanese respondents exaggerated the seriousness case. In clinical applications, a false–positive case
of their conditions. Although the validity of the
FAS as related to the overall ratings of the CFI Table 5
was weak, the validity of FAS relative to the Relatives’ characteristics in high-FAS and low-FAS groups
HCCyLCC ratings of the CFI was good; the
High FAS Low FAS
sensitivity was 100% and the specificity was (ns11) (ns46)
88.5%. The concept of CC is valuable in the
clinical situation. For example, the effects of psy- GHQ-30 (mean"S.D.) 9.9"5.5 7.6"6.5
choeducational intervention for relatives are GHQ-60 (mean"S.D.) 19.9"11.6 14.7"11.6
expected to be optimal in high-CC families (Shi- Physicala (mean"S.D.)* 3.5"2.3 1.9"1.9
Anxietyb (mean"S.D.) 3.6"2.1 2.7"2.0
modera et al., 2000a). Socialc (mean"S.D.) 2.0"2.1 1.6"2.0
The FMSS has been used in many studies and Depression (mean"S.D.) 0.9"1.8 0.8"1.7
is deemed to be a reliable method for the assess- a
Physical symptoms.
ment of EE (Malla et al., 1991; Shimodera et al., b
Anxietyyinsomnia.
1999). In this study, however, the validity of the c
Social dysfunction.
FMSS was inferior to that of the FAS. The data *
P-0.05.
 H. Fujita et al. / Psychiatry Research 110 (2002) 273–280
in this sense would not indicate serious problems.
For example, when the intervention for relatives
who were rated HCC with the FAS is planned, we
could include some low-EE relatives rated with
the CFI. Although there are some negative findings
in low-EE families (Linszen et al., 1996), it is
largely supported that all kinds of families benefit
from family intervention (Falloon et al., 1982;
Leff et al., 1982). However, because of limited
resources in clinical settings, the development of
effective screening measures to identify the fami-
lies most in need of and most likely to benefit
from psychoeducational interventions is an impor-
tant goal.
The mean score on the GHQ-60 was higher in
the high-FAS group. In particular, mean scores on
the physical subscales were significantly higher in
the high-FAS group. In the study of the relation-
ships of EE with family distress, GHQ scores were
higher in the high-EE groups assessed by the CFI
(Barrowclough and Parle, 1997; Shimodera et al.,
2000b). Similar results were obtained with the
FAS. Although the mental health of the family is
of concern irrespective of the family’s EE level, it
seems that greater attention may be needed when
the FAS score is high.
There are several limitations of this study. First,
the sample is relatively small. The comparison
between the high-FAS group and the low-FAS
group is hampered by the small size of the former
group. This might explain the low sensitivity of
the FAS relative to the overall CFI. Second, only
43 of 61 families consented to enrol in the study,
and furthermore the rate of HCC families was
lower in this study sample compared with that in
an earlier study conducted at the same institution
(Tanaka et al., 1995). Although there were no
significant differences in the characteristics
between the enrolled families and those who
refused to participate, there might be many highly
critical families among those that refused. Third,
the FAS, like the FMSS, is not a good measure of
high EOI. In the case of the FMSS, this may be
largely due to its brevity. EOI ratings are mainly
based on reported behaviour, and such information
is unlikely to be forthcoming in the first 5 min of
an interview. The problem with the FAS is different
in kind and probably reflects its nature as a self-
279
report instrument with a restricted number of
questions. Despite this limitation, the FAS is an
adequate proxy measure for the more time-con-
suming CFI in the assessment of critical attitudes
among relatives. We will later report the outcome
of a 9-month study of the same patients to evaluate
the power of the FAS to predict clinical outcomey
relapse.
References
American Psychiatric Association, 1994. Diagnostic and Sta-
tistical Manual of Mental Disorders, 4th ed. APA, Washing-
ton, DC.
Andreasen, N.C., 1983. The Scale for the Assessment of
Negative Symptoms (SANS). University of Iowa, Iowa
City.
Andreasen, N.C., 1982. Negative versus positive schizophre-
nia: definition and validation. Archives of General Psychi-
atry 39, 789–794.
Baker, B., Helmes, E., Kazarian, S.S., 1984. Past and present
perceived attitudes of schizophrenics in relation to rehospi-
talization. British Journal of Psychiatry 144, 263–269.
Barrowclough, C., Parle, M., 1997. Appraisal, psychological
adjustment and expressed emotion in relatives of patients
suffering from schizophrenia. British Journal of Psychiatry
171, 26–30.
Barrowclough, C., Tarrier, N., 1990. Social functioning in
schizophrenic patients. I. The effects of expressed emotion
and family intervention. Social PsychiatryyPsychiatric Epi-
demiology 25, 125–129.
Bebbington, P., Kuipers, L., 1994. The predictive utility of
expressed emotion in schizophrenia: an aggregate analysis.
Psychological Medicine 24, 707–718.
Falloon, I.R., Boyd, J.L., McGill, C.W., Razani, J., Moss,
H.B., Gilderman, A.M., 1982. Family management in the
prevention of exacerbations of schizophrenia: a controlled
study. New England Journal of Medicine 306, 1437–1440.
Fletcher, R.H., Fletcher, S.W., Wagner, E.H., 1996. Clinical
Epidemiology, the Essentials, 3rd ed. Williams & Wilkins
Company, Baltimore.
Gerlsma, C., Hale, W.W., 1997. Predictive power and construct
validity of the Level of Expressed Emotion (LEE) Scale:
depressed out-patients and couples from the general com-
munity. British Journal of Psychiatry 170, 520–525.
Goldberg, D., Williams, P.A., 1988. User’s Guide to the
General Heath Questionnaire. NEFR-Nelson, Windsor, UK.
Hooley, J.M., Orley, J., Teasdale, J.D., 1986. Levels of
expressed emotion and relapse in depressed patients. British
Journal of Psychiatry 148, 642–647.
Inoue, S., Tanaka, S., Shimodera, S., Mino, Y., 1997. Expressed
emotion and social function. Psychiatry Research 72, 33–39.
Kavanagh, D.J., O’Halloran, P., Manicavasagar, V., Clark, D.,
Piatkowska, O., Tennant, C., Rosen, A., 1997. The Family
Attitude Scale: reliability and validity of a new scale for
280 H. Fujita et al. / Psychiatry Research 110 (2002) 273–280
measuring the emotional climate of families. Psychiatry
Research 70, 185–195.
Kazarian, S.S., Malla, A.K., Cole, J.D., Baker, B., 1990.
Comparisons of two expressed emotion scales with the
Camberwell Family Interview. Journal of Clinical Psychol-
ogy 46, 306–309.
Kitamura, T., Sugawara, M., Aoki, M., Shima, S., 1989.
Validity of the Japanese version of the GHQ among ante-
natal clinic attendants. Psychological Medicine 19, 507–511.
Kokakowska, T., 1976. Brief Psychiatric Rating Scale, Glos-
saries and Rating Instruction. Department of Psychiatry,
Oxford University, Oxford.
Leff, J., Kuipers, L., Berkowitz, R., Eberlein-Vries, R., Stur-
geon, D., 1982. A controlled trial of social intervention in
the families of schizophrenic patients. British Journal of
Psychiatry 141, 121–134.
Leff, J., Vaughn, C., 1985. Expressed Emotion in Families.
Guilford Press, New York.
Linszen, D., Dingemans, P., Van Der Does, J.W., Nugter, A.,
Scholte, P., Leinior, R., Golstein, M.J., 1996. Treatment,
expressed emotion and relapse in recent onset schizophrenic
disorders. Psychological Medicine 26, 333–342.
˜ A.B., Goldstein, J.M., Karno, M., Miklowitz, D.J.,
Magana,
Jenkins, J., Falloon, I.R., 1986. A brief method for assessing
expressed emotion in relatives of psychiatric patients. Psy-
chiatry Research 17, 203–212.
Malla, A.K., Kazarian, S.S., Barnes, S., Cole, J.D., 1991.
Validation of the five-minute speech sample in measuring
expressed emotion. Canadian Journal of Psychiatry 36,
297–299.
Mino, Y., Inoue, S., Shimodera, S., Tanaka, S., Tsuda, T.,
Yamamoto, E., 1998. Expressed emotion of families and
negativeydepressive symptoms in schizophrenia: a cohort
study in Japan. Schizophrenia Research 34, 159–168.
Mino, Y., Tanaka, S., Tsuda, T., Babazono, A., Inoue, S.,
Aoyama, H., 1995. Training in evaluation of expressed
emotion using the Japanese version of the Camberwell
Family Interview. Acta Psychiatrica Scandinavica 92,
183–186.
Nakagawa, Y., Daibo, I., 1985. Japanese Version of the General
Health Questionnaire. Nihon Bunka Kagakusha, Tokyo. wIn
Japanesex.
Overall, J.E., Gorham, D.P., 1962. The Brief Psychiatric Rating
Scale. Psychological Reports 10, 799–812.
Parker, G., Tupling, H., Brown, L.B., 1979. A parental bonding
instrument. British Journal of Medical Psychology 52, 1–10.
Shimodera, S., Inoue, S., Mino, Y., Tanaka, S., Kii, M., Motoki,
Y., 2000. Expressed emotion and psychoeducational inter-
vention for relatives of patients with schizophrenia: a ran-
domized controlled study in Japan. Psychiatry Research 96,
141–148.
Shimodera, S., Mino, Y., Inoue, S., Izumoto, Y., Fujita, H.,
Ujihara, H., 2000. Expressed emotion and family distress in
relatives of patients with schizophrenia in Japan. Compre-
hensive Psychiatry 41, 392–397.
Shimodera, S., Mino, Y., Inoue, S., Izumoto, Y., Kishi, Y.,
Tanaka, S., 1999. Validity of a five-minute speech sample
in measuring expressed emotion in the families of patients
with schizophrenia in Japan. Comprehensive Psychiatry 40,
372–376.
Tanaka, S., Mino, Y., Inoue, S., 1995. Expressed emotion and
the course of schizophrenia in Japan. British Journal of
Psychiatry 167, 794–798.
Thompson, M.C., Goldstein, M.J., Lebell, M.B., Mintz, L.I.,
Marder, S.R., Mintz, J., 1995. Schizophrenic patients’ per-
ceptions of their relatives’ attitudes. Psychiatry Research 57,
155–167.
Uehara, T., Yokoyama, T., Goto, M., Kohmura, N., Nakano,
Y., Toyooka, K., Ihda, S., 1997. Expressed emotion from
the five-minute speech sample and relapse of out-patients
with schizophrenia. Acta Psychiatrica Scandinavica 95,
454–456.
Vaughn, C., Leff, J., 1976. The measurement of expressed
emotion in the families of psychiatric patients. British
Journal of Social and Clinical Psychology 15, 157–165.
World Health Organization, 1992. The ICD-10 Classification
of Mental and Behavioural Disorders, Clinical Description
and Diagnostic Guidelines. WHO, Geneva.