Psychiatry Research 247 (2017) 323–329

Contents lists available at ScienceDirect

Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Relatives' expressed emotion, distress and attributions in clinical high-risk MARK

and recent onset of psychosis
Tecelli Domínguez-Martíneza, Cristina Medina-Pradasb,c, Thomas R. Kwapild,
⁎
Neus Barrantes-Vidale,f,g,
a
CONACYT- Instituto Nacional de Psiquiatría “Ramón de la Fuente Muñiz”, Dirección de Investigaciones Epidemiológicas y Psicosociales, Mexico City,
Mexico
b
Departamento de Educación, Universidad Internacional de La Rioja, Spain
c
Departamento de Personalidad, Evaluación y Tratamientos Psicológicos, Universidad de Sevilla, Sevilla, Spain
d
Department of Psychology, University of Illinois at Urbana-Champaign, USA
e
Departament de Psicologia Clínica i de la Salut, Universitat Autònoma de Barcelona, Spain
f
Departament de Salut Mental. Sant Pere Claver- Fundació Sanitària, Barcelona, Spain
g
Centre for Biomedical Research Network on Mental Health (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain

A R T I C L E I N F O A BS T RAC T

Keywords: It has been well-demonstrated that Expressed Emotion (EE) in caregivers of schizophrenia patients is related to
Early psychosis their illness attributions, but little is known about relatives' cognitive and emotional appraisals at early stages of
Criticism psychosis. This study examined differences on the relationships of EE with distress and illness attributions in 78
Emotional over-involvement relatives of At-Risk Mental States (ARMS) and First-Episode of Psychosis (FEP) patients, and which of those
Distress
variables better predicted EE. Criticism and Emotional Over-Involvement (EOI) were associated with distress
Family
and with several illness attributions in both groups. Anxiety was more strongly associated with criticism in
Appraisals
ARMS than in FEP-relatives, and it was associated with EOI in the ARMS but not in the FEP-group. No
differences on the relationships of EE with depression or attributions were found. Furthermore, distress and
attributions of blame toward the patients predicted criticism. Attributions of control by the patient and
emotional negative representation about the disorder predicted EOI. Findings highlight the need to focus on
early family interventions that provide proper information and psychological support in accordance with the
illness stage, to help relatives improve their understanding of the disorder, handle difficult thoughts and
emotions, reduce negative appraisals, and prevent high-EE over the psychotic process.

1. Introduction
Adapting to life with a relative affected by a mental disorder is often
a stressful experience that creates a sense of subjective burden and
distress in family members (Jungbauer and Angermeyer, 2002). There
is substantial evidence in the literature demonstrating that the
responsibility of caring for a family member with a psychotic disorder
can lead to show elevated levels of distress, anxiety, and depression in
caregivers (Barrowclough et al., 1996; Jansen et al., 2015a, 2015b). In
the early stages of psychosis, caregivers face a number of issues, such as
shock, grief, poor understanding of illness and the psychiatric system
(Onwumere et al., 2011). In fact, Martens and Addington (2001) have
reported higher levels of distress in relatives of early psychosis patients
than those of individuals who have a more chronic course of illness.
Some studies have found that distress in caregivers of persons with
First-Episode of Psychosis (FEP) seems to be more related to their
subjective appraisal of the impact of illness and over-involvement than
to variations in the patients’ symptomatology and overall functioning in
the early phase of illness (Addington et al., 2003). However, little is
known about the psychological underpinnings of caregiver distress in
early psychosis and further research could improve our understanding
of the trajectory of distress early in the course of illness and assist in
developing strategies for preventing long-term distress in caregivers
and supporting recovery in the whole family (Jansen et al., 2015a,
2015b).
In relation to family caring role, one of the most influential concepts
in psychosocial research on psychosis has been Expressed Emotion
(EE), a measure of the family emotional environment comprised of

⁎
Correspondence to: Departament de Psicologia Clínica i de la Salut. Facultat de Psicologia. Edifici B. Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Bellaterra 08193,
Barcelona, Spain.
E-mail address: neus.barrantes@uab.cat (N. Barrantes-Vidal).

http://dx.doi.org/10.1016/j.psychres.2016.11.048
Received 13 May 2016; Received in revised form 23 November 2016; Accepted 29 November 2016
Available online 30 November 2016
0165-1781/ © 2016 Elsevier Ireland Ltd. All rights reserved.

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T. Domínguez-Martínez et al.
stances expressed by relatives towards an ill family member (Vaughn
and Leff, 1985). Given that high-EE, defined by the presence of
elevated levels of criticism, hostility and/or Emotional Over-
Involvement (EOI), has consistently shown to be an important
predictor of relapse in schizophrenia (Brown et al., 1972; Butzlaff
and Hooley, 1998), much research has focused on trying to understand
the psychological factors that underlie this construct.
For instance, the attributional model (Barrowclough and Hooley,
2003) postulates that relatives' EE attitudes are related to their beliefs
about the causes and nature of the mental disorder. Several studies
have shown that, in the absence of adequate information about the
disorder, caregivers are likely to make attributions that psychotic
symptoms are under the patient control or are their responsibility. In
consequence, relatives who believe that patients might control over
their behaviours or blame them for their symptoms may react with
criticisms in an attempt to reduce those behaviours (Weisman et al.,
1998). On the other hand, it has been suggested that emotionally
overinvolved relatives tend to believe that they have somehow con-
tributed to the patient's problems, so they usually present self-blaming
attributions (Bentsen et al., 1998).
Most EE and related factors studies in the field of psychosis have
been carried out with patients with chronic psychosis or schizophrenia
(Kavanagh, 1992; Hooley, 2007), although the recent focus of research
on early stages of the psychotic continuum has led to an increasing
interest in the study of EE, in order to prevent the entrenchment of
high-EE and relapses. Preliminary research have found that high-EE is
present in approximately the half of the relatives of FEP patients
(Bachmann et al., 2002; Heikkilä et al., 2002) and is also present even
in relatives of persons at-risk for psychosis (O´Brien et al., 2006;
Schlooser et al., 2010). In addition, recent findings indicated that
caregivers of patients with early psychosis presented significant emo-
tional problems and, that higher levels of EE are related with
caregivers' burden and with elevated levels of anxiety and depression
at these early psychosis stages (Tomlinson et al., 2014; Boydell et al.,
2014; Barrowclough et al., 2014).
In a prior study, our team investigated the prevalence of EE indices
in relatives of both FEP and At-Risk Mental States (ARMS) patients,
and we demonstrated that illness attributions mediate the relationship
of EE with clinical and functional symptoms at these stages
(Domínguez-Martínez et al., 2014). Furthermore, some studies have
shown that relatives’ cognitive representation of psychosis may play an
important role in their emotional appraisals even at early stages of the
disorder (Onwumere et al., 2008) and that critical relatives of FEP
patients are also more likely to believe that the problematic behaviours
are controlled by the patient (McNab et al., 2007; Vasconcelos et al.,
2013). Nevertheless, far less is known about psychological character-
istics associated to relatives' levels of EE in early psychosis phases and
more research is need at this regard, especially in ARMS population. In
addition, both groups of FEP and ARMS relatives have been rarely
compared in these questions (Domínguez-Martínez et al., 2014;
Meneguelli et al., 2011), so it remains unclear if the nature of relatives'
EE, distress and illness beliefs differs from a subclinical to a recent
stage of psychosis.
Considering the crucial role of family environment in the prognosis
of psychosis and the benefits that early family intervention could
provide in preventing the development of misguided beliefs and
negative emotions in relatives at these early stages of the psychotic
process, it would be necessary to improve our understanding of the
relatives’ psychological factors that could be related to their levels of
EE, such as distress and illness beliefs, as well as to examine whether
these family factors predict in some way the EE. Thus, the following
aims were addressed at this study: 1) To describe and compare the
levels of EE (criticism and EOI), distress (levels of anxiety and
depression), and several illness attributions in relatives of ARMS and
FEP patients; 2) To examine the associations of EE with relatives'
distress and illness attributions, as well as differences of these
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Psychiatry Research 247 (2017) 323–329
associations between ARMS and FEP groups; and 3) To explore
whether relatives' distress and illness attributions predict EE in both
groups. Based on the attributional model and on previous findings, we
hypothesized that: a) FEP-relatives would show higher levels of EOI,
depression and both self-blame and self-control attributions than
ARMS-relatives, who would show higher levels of criticism, anxiety
and attributions of control and blame towards the patients than FEP-
relatives; b) In both groups, EOI would be associated with anxiety and
depression, attributions of self-blame and self-control, as well as with
negative emotional representation of the disorder, whereas criticism
would be associated with relatives’ belief that patients can control their
symptoms and with the attribution of blame toward the patient; and c)
illness attributions would predict EE in all the relatives. In particular,
beliefs of self-blame, self-control and negative emotional representa-
tion of the disorder would predict EOI, while beliefs of control and
blame toward the patient would predict criticism.
2. Methods
2.1. Participants
This study comprises 78 relatives, 41 of ARMS and 37 of FEP
patients. They were recruited within the Sant Pere Claver-Early
Psychosis Program conducted in Barcelona, Spain (Domínguez-
Martínez et al., 2011), if they had regular contact and/or the most
significant relationship with the patient. Patients met ARMS criteria as
assessed by the Comprehensive Assessment of At-Risk Mental States
(CAARMS) (Yung et al., 2005) or FEP criteria according to DSM-IV-TR
(American Psychiatric Association, 2002).
All participants provided written informed consent. The project was
developed in accordance with the Code of Ethics of the World Medical
Association (Declaration of Helsinki) and has been approved by the
local ethical committee.
2.2. Measures
EE was assessed with the Family Questionnaire (FQ) (Wiedemann
et al., 2002), which comprises 20-items equally distributed in two
subscales (criticism and EOI) scored on a 4-point scale ranging from
‘never/very rarely’ to ‘very often’. The Depression and Anxiety sub-
scales of the Symptom Checklist (SCL-90-R) (Derogatis and Cleary,
1977) were used to assess relatives' distress. The SCL-90-R is a
psychiatric self-report inventory intended to measure symptom inten-
sity on a five-point scale from 0 'not at all' to 4 'extremely'. Illness
Attributions were assessed with the Illness Perceptions Questionnaire
for Schizophrenia-Relatives' version (IPQS-R) (Lobban et al., 2005), a
measure of relatives' beliefs about the disorder whose items are rated
from 1 ‘strongly disagree’ to 5 ‘strongly agree’. For the purposes of this
study we used the following subscales: cause (personal ideas about the
cause of the disorder), timeline acute/chronic and timeline cyclical
(perception of the pattern and duration of the disorder), consequences
for both patients and relative (the expected effects and outcome of the
disorder), personal control-patient and personal control-relative (con-
trol over the disorder), personal blame-patient and personal blame-
relative (blame toward the patient or self-blame about the disorder),
treatment control/cure (usefulness of treatment), illness coherence (a
coherent understanding of the disorder) and emotional representation
(negative emotions about the disorder including sense of fear, frustra-
tion, anger, loss, worry). In order to explore causal attributions more in
depth, individual items of the cause-subscale were also ranked in terms
of strength of belief as indicated by their authors.
2.3. Statistical analyses
First, descriptive data were analyzed (means and standard devia-
tions or percentages, depending on the nature of the variables). Second,
T. Domínguez-Martínez et al. Psychiatry Research 247 (2017) 323–329

to analyze the differences between ARMS and FEP relatives, chi-square Table 1
or Fisher's exact test when appropriate were calculated on categorical Descriptive data on socio-demographic characteristics and comparisons
between ARMS and FEP relatives (N=78).
variables, and Student t-test was used on continuous variables. Third,
linear regressions were computed to examine the associations of EE ARMS- FEP-Relatives Comparisons
indices (criticism and EOI) with distress and illness attributions, group Relatives n=37
differences (ARMS-Relatives vs. FEP-Relatives) and their interaction n=41
(Criticism/EOI×group). The effect size (Cohen's f2) was also presented
n (%) n (%) Statistics
according to Cohen's guidelines (medium effect: magnitude > 0.15,
large effect: magnitude > 0.35) (Cohen, 1998). Finally, hierarchical Age (mean, SD) 50.5 (10.1) 51.1 (12.4) t(67)=−0.21;
regression analysis was performed in order to probe our last hypoth- p=0.82
esis, that is, whether relatives' attributions of control, blame and Gender Fisher's Exact Test
Males 13 (31.7) 16 (43.2) p=0.35
negative emotional representation predicted EE components according Females 28 (68.3) 21 (56.8)
to the attributional model. Ethnicity Fisher's Exact Test
Caucasian-white 29 (70.7) 32 (86.5) p=0.19
Other 12 (29.3)a 5 (13.5)b
Education χ2=0.66; df=2;
3. Results
Primary school 9 (22) 8 (21.6) p=0.65
Secondary school 25 (61) 20 (54.1)
3.1. Description and comparison of ARMS and FEP relatives on University or higher 7 (17.1) 9 (24.3)
socio-demographic characteristics, EE, distress, and illness Occupation Fisher's Exact Test
attributions Unemployed/ 15 (36.6) 18 (48.6) p=0.28
Unoccupied
Employee 26 (63.4) 19 (51.4)
Most of relatives were parents who lived with the patient. Over half Marital statusc
of them were employee and married (please see Table 1 for details Single 1 (2.4) 2 (5.4)
about relatives' socio-demographic characteristics). No significant Married or 26 (63.4) 26 (70.3)
analogous
differences between ARMS and FEP relatives were found on socio-
Separated/Divorced 11 (26.8) 6 (16.2)
demographic variables. Widowed 3 (7.3) 3 (8.1)
Descriptive data on relatives’ levels of EE, distress, and illness Relationship to Fisher's Exact Test
attributions, as well as mean comparisons between ARMS and FEP patient p=0.14
groups, can be seen in Table 2. ARMS-relatives scored higher in Parent 39 (90.2) 31 (83.7)
Other 2 (4.9) 6 (16.2)
criticism and in the attribution of a cyclic pattern of the disorder than
Living with the Fisher's Exact Test
FEP-relatives (see Table 2). No differences were found between ARMS patient p=0.74
and FEP groups in the other studied variables. Yes 35 (85.4) 33 (89.2)
Regarding further analyses of causal attributions, the most strongly No 6 (14.6) 4 (10.8)
Frequency of χ2= 1.36; df= 2;
held beliefs of both ARMS and FEP relatives were that the disorder had
contactd p=0.51
been caused by patient stress or worry and because patients think too Between 1 and 14 h 11 (35.5) 15 (50.0)
much about things. Besides, ARMS-relatives believed that patient's a week
problems were caused by patients’ personality and mental attitude (e.g. Between 15 and 6 (19.4) 4 (13.3)
thinking about life negatively). 27 h a week
≥ 28 h a week 14 (45.2) 11 (36.7)

Abbreviations: ARMS: At-Risk Mental State; FEP: First-Episode Psychosis; SD: Standard Deviation.
3.2. Associations of EE with distress and illness attributions in ARMS a
Other ethnicity in the ARMS group was comprised by Latin Americans=8 (19.5%) and Asians=4 (5.1%).
b
and FEP relatives Other ethnicity in the FEP group was comprised by Latin Americans=2 (5.4%), Eastern Europeans=2 (2.6%)

and Arabs=1 (1.3%).

Overall, EE indices (criticism and EOI) were strongly associated
with relatives' distress and with several illness attributions (Please see
Tables 3, 4). In concrete, both EE-criticism and EE-EOI were strongly
associated with levels of anxiety and depression, as well as with
attributions of timeline-cyclical (which refer to a perception of a more
cyclical or episodic pattern of the disorder over time), attributions of
greater negative consequences of the disorder for both the patient and
the relative, attributions of blame toward the patient, and emotional
representation (which reflects negative emotions about the disorder).
Additionally, criticism was related to causal attributions and attribu-
tion of illness coherence (which reflects the sense of not having a
comprehensive understanding of the disorder), whereas EOI was
related to timeline-acute/chronic (the perception of an acute/chronic
pattern of the disorder over time). Neither self-blame attributions nor
attributions of control were associated with EE indices.
Differences between groups were found on the association between
anxiety and EE components (please see Table 3 and Table 4), so that
anxiety was more strongly associated with criticism in ARMS than in
FEP relatives (ARMS: b=4.53 (SE=0.98), beta=0.63, t=4.60, p=0.000;
FEP: b=1.97 (SE=0.73), beta=0.43, t=2.70, p=0.01), and it was
associated with EOI in ARMS but not in the FEP group (ARMS:
b=4.14 (SE=0.97), beta=0.57, t=4.26, p=0.000; FEP: b=0.88
(SE=0.73), beta=0.21, t=1.20, p=0.24).
c
The chi-square is uninterpretable because minimum expected value is < 5.
d
Information about frequency of contact was available only for n=61.
3.3. Predictors of EE in ARMS and FEP relatives
Anxiety, depression and attributions of blame toward the patient
significantly accounted for variance in EE-criticism, whereas attribu-
tions of control by the patient and emotional negative representation
about the disorder significantly account for variance in EE-EOI (see
Table 5).
4. Discussion
This study explores the association between family EE, relatives'
distress and illness attributions in relatives of patients at clinical high-
risk and recent-onset psychosis. Findings showed that (i) ARMS-
caregivers were more critical toward their ill relatives and perceived
that the pattern of the disorder will be cyclical over time as compared to
FEP-caregivers; (ii) criticism and EOI were highly associated with both
anxiety and depression, and with several types of illness attributions;
(iii) anxiety and EE were related differently in ARMS and in FEP
relatives; and (iv) relatives' levels of anxiety and depression, negative
emotions about the disorder, and attributions of control and blame

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Table 2
Descriptive data on Expressed Emotion, Distress, and Illness Attributions and comparisons between ARMS and FEP relatives (N=78).

ARMS-Relatives n=41 FEP-Relatives n=37 Mean comparisons Effect size

α Possible score range Observed score range Mean (SD) Observed score range Mean (SD) t-value (df) Cohen's d

Expressed Emotion (FQ)

Criticisma 0.86 10–40 10–37 22.4 (6) 10–32 18.5 (6) 2.85 (76);p=0.006 0.64
EOIa 0.78 10–40 15–36 24.1 (5.2) 14–35 23.5 (5.7) 0.50 (76); p=0.62 0.11
Distress (SCL-90-R)
Anxietyb 0.82 0–40 0–34 7.4 (7.1) 0–20 5.0 (4.2) 1.80 (62.9); p=0.76 0.41
Depressionb 0.88 0–52 0–43 15.1 (10.1) 0–34 11.6 (8.2) 1.64 (74); p=0.11 0.38
Illness Attributions (IPQS-R)
Causesc 0.87 25–125 32–120 66.2 (16.9) 34–91 60.8 (15.0) 1.40 (69); p=0.16 0.34
Timeline-acute/chronicd 0.83 6–30 6–30 17.5 (4.4) 7–30 16.1 (4.8) 1.37 (75); p=0.18 0.30
Timeline-cyclicale 0.90 4–20 4–20 13.2 (4.0) 4–20 10.8 (4.5) 2.52 (76);p=0.01 0.56
Consequences-patientf 0.82 11–55 18–53 34.1 (8.1) 18–47 32.1 (8.5) 1.08 (75); p=0.28 0.24
Consequences-relativef 0.76 9–45 12–42 22.8 (7.1) 13–40 23.0 (6.7) −0.10 (75); p=0.92 −0.02
Personal control-patientg 0.63 4–20 7–18 14.3 (2.7) 5–20 14.4 (3.3) −0.105 (75); p=0.92 −0.03
Personal control-relativeg 0.63 4–20 6–18 12.9 (2.7) 6–20 13.4 (3.1) −0.793 (74); p=0.43 −0.17
Personal blame-patienth 0.82 3–15 3–15 10.3 (3.0) 3–15 9.1 (3.2) 1.66 (76); p=0.10 0.38
Personal blame-relativeh 0.83 3–15 3–12 8.2 (2.5) 3–13 7.0 (2.9) 1.82 (75); p=0.07 0.44
Treatment control/curei 0.76 5–25 9–25 17.8 (3.6) 11–25 18.6 (3.1) −1.16 (76); p=0.25 −0.23
Illness coherencej 0.79 5–25 6–23 14.4 (4.3) 6–23 12.6 (4.3) 1.83 (74); p=0.07 0.41
Emotional representationk 0.78 9–45 13–40 28.1 (7.1) 10–41 27.4 (6.1) 0.50 (73); p=0.62 0.10

Abbreviations: ARMS: At-Risk Mental State; FEP: First-Episode Psychosis; SD: Standard Deviation; FQ: Family Questionnaire; EOI: Emotional Over-Involvement; SCL-90-R: Symptom Checkllist-90-Revised; IPQS-R: Illness Perception

Questionnaire for Schizophrenia Relatives' version.

Significant at p < 0.05 (two-tailed) are bolded.

a
A high score indicate higher levels of Criticism or Emotional Over-Involvement.
b
A high score indicate higher levels of anxiety or depression.
c
Individual items of the cause-subscale were ranked in terms of strength of belief as indicated by their authors and the interpretation is described in Results section.
d
A high score reflects a perception of a more chronic timeline.
e
A high score reflects the perception of a more cyclical pattern of mental health problems over time.
f
A high score reflects a perception of greater negative consequences for the patient/relative.
g
A high score reflects a perception of greater control by the patient/relative.
h
A high score reflects attributions of blame towards the patient/relative.
i
A high score reflects the belief that treatment can be effective in alleviating the mental health problems.
j
A high score reflects the sense of having no coherent understanding of the mental health problems.
k
A high score reflects a high negative emotional response to the patient's mental health problems.

toward the patient predicted EE. These results partially confirmed our
hypotheses and are consistent with findings in the schizophrenia
literature, as they show that relatives' distress and cognitive represen-
tations of psychosis are strongly linked to their negative emotional
attitudes toward patients. In addition, they indicate that this occurs
even in the early stages of psychosis.
Overall, ARMS and FEP relatives showed scarce differences on EE,
distress and illness attributions. In particular, ARMS-relatives pre-
sented higher levels of criticism and the perception that the pattern of
the disorder will be episodic/cyclical over time than those of FEP-
relatives, maybe due to the nonspecific nature of the ARMS stage. As
the disorder progresses and full psychotic symptoms emerge, relatives
gain more knowledge about the illness and likely this may contribute to
decreasing criticism levels towards the affected relative and to shaping

Table 3
Associations of Distress and Illness attributions with EE-CRITICISM, differences by groups (ARMS vs. FEP) and interaction (Criticism×Group) (N=78).

Criterion Step 1 EE-Criticism Step 2 Group (ARMS vs. FEP) Step 3 Interaction (EE-Criticism×Group)

β p Δr2 f2 β P Δr2 f2 β P Δr2 f2

Distress (SCL-90-R)
Anxiety 0.558 0.000 0.311 0.45 −0.002 0.99 0.000 0.00 −0.279 0.05 0.039 0.06
Depression 0.554 0.000 0.296 0.42 −0.012 0.91 0.000 0.00 −0.047 0.74 0.001 0.00
Illness Attributions (IPQS-R)
Cause 0.246 0.04 0.061 0.06 −0.100 0.42 0.009 0.01 0.119 0.47 0.007 0.01
Timeline-acute/chronic 0.189 0.10 0.036 0.04 −0.106 0.38 0.010 0.03 0.131 0.42 0.008 0.03
Timeline-cyclical 0.332 0.003 0.111 0.12 −0.193 0.09 0.033 0.03 0.219 0.15 0.024 0.02
Consequences-patient 0.315 0.005 0.099 0.11 −0.033 0.78 0.001 0.00 0.041 0.79 0.001 0.00
Consequences-relative 0.309 0.007 0.095 0.10 0.120 0.31 0.013 0.01 0.188 0.23 0.017 0.02
Personal control-patient 0.179 0.12 0.032 0.03 0.073 0.55 0.005 0.01 0.122 0.45 0.007 0.01
Personal control-relative 0.029 0.80 0.001 0.00 0.110 0.37 0.011 0.01 −0.199 0.38 0.020 0.02
Personal blame-patient 0.400 0.000 0.160 0.19 −0.069 0.54 0.004 0.00 0.173 0.25 0.015 0.02
Personal blame-relative 0.146 0.21 0.021 0.02 −0.179 0.14 0.029 0.03 −0.048 0.77 0.001 0.00
Treatment control/cure −0.154 0.18 0.024 0.02 0.093 0.44 0.008 0.01 0.033 0.84 0.001 0.00
Illness coherence 0.252 0.03 0.064 0.07 −0.147 0.21 0.020 0.02 −0.200 0.21 0.020 0.02
Emotional representation 0.266 0.02 0.071 0.08 0.018 0.88 0.000 0.00 −0.151 0.35 0.011 0.01

Abbreviations: EE: Expressed Emotion, ARMS: At-Risk Mental State; FEP: First-Episode Psychosis; EE: Expressed Emotion; SCL-90-R: Symptom Checkllist-90-Revised; IPQS-R: Illness Perception Questionnaire for Schizophrenia-Relatives'

version.

Medium and large effect sizes (f2) in italics.

Significant at p < 0.05 (two-tailed) are bolded.

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Table 4
Associations of Distress and Illness Attributions with EE-EOI, differences by groups (ARMS vs. FEP) and interaction (EOI×Group) (N=78).

Criterion Step 1 EE-EOI Step 2 Group (ARMS vs. FEP) Step 3 Interaction (EE-EOI×Group)

β p Δr2 f2 β p Δr2 f2 β p Δr2 f2

Distress (SCL-90-R)
Anxiety 0.448 0.000 0.201 0.25 −0.148 0.17 0.021 0.03 −0.367 0.01 0.070 0.10
Depression 0.428 0.000 0.183 0.22 −0.152 0.15 0.023 0.03 −0.219 0.14 0.024 0.03
Illness Attributions (IPQS-R)
Cause 0.009 0.94 0.000 0.00 −0.167 0.17 0.028 0.00 −0.079 0.64 0.003 0.00
Timeline-acute/chronic 0.271 0.02 0.074 0.08 −0.142 0.20 0.020 0.02 0.077 0.63 0.003 0.00
Timeline-cyclical 0.355 0.001 0.126 0.14 −0.258 0.02 0.066 0.08 0.106 0.48 0.005 0.00
Consequences-patient 0.402 0.000 0.161 0.19 −0.110 0.30 0.012 0.02 −0.110 0.46 0.006 0.01
Consequences-relative 0.270 0.02 0.073 0.08 0.034 0.76 0.001 0.00 0.081 0.62 0.003 0.00
Personal control-patient 0.106 0.36 0.011 0.01 0.017 0.88 0.000 0.00 0.022 0.90 0.000 0.00
Personal control-relative 0.196 0.90 0.038 0.04 0.102 0.38 0.010 0.01 −0.210 0.20 0.021 0.02
Personal blame-patient 0.286 0.01 0.082 0.09 −0.171 0.12 0.029 0.03 0.044 0.78 0.001 0.00
Personal blame-relative 0.065 0.57 0.004 0.00 −0.203 0.08 0.041 0.04 −0.065 0.69 0.002 0.00
Treatment control/cure 0.063 0.58 0.004 0.00 0.136 0.24 0.018 0.02 −0.105 0.53 0.005 0.01
Illness coherence 0.066 0.58 0.004 0.00 −0.205 0.08 0.042 0.04 −0.007 0.97 0.000 0.00
Emotional representation 0.527 0.000 0.278 0.39 −0.043 0.67 0.002 0.00 −0.144 0.33 0.010 0.01

Abbreviations: EE: Expressed Emotion, ARMS: At-Risk Mental State; FEP: First-Episode Psychosis; EE: Expressed Emotion; EOI: Emotional Over-Involvement; SCL-90-R: Symptom Checkllist-90-Revised; IPQS-Relatives' version: Illness

Perception Questionnaire for Schizophrenia.

Medium and large effect sizes (f2) in italics; Significant at p < 0.05 (two-tailed) are bolded.

Table 5 considered that in prodromal stages EOI should not be always

Predictors of Expressed Emotion in ARMS and FEP relatives (N=78). considered as a negative side of family members' reactions, but as an
understandable reaction to a crisis and an adaptive mechanism that
EE-Criticism EE-EOI
might serve as a testimony of the family's concern about patients' well-
Step Predictors β p Δr2 β p Δr2 being and commitment to deal with the symptoms and their con-
sequences (Schlooser et al., 2010; Van et al., 2001) however, on the
1 Distress 0.365; 0.211; other hand, EOI in FEP-relatives has shown to be related with family
(SCL-90-R) p=0.000 p=0.000
Anxiety 0.308 0.04 0.306 0.07
stress and more negative experiences of caregiving (Álvarez-Jiménez
Depression 0.336 0.03 0.182 0.28 et al., 2010; Jansen et al., 2013, 2015a, 2015b).
Illness 0.109; 0.316; Consistent with previous studies (Weisman et al., 1998;
Attributions p=0.000 p=0.000 Domínguez-Martínez et al., 2014), it was found that criticism was
(IPQS-R)
associated with attributions of blame toward the patient. This finding is
2 Personal 0.168 0.14 0.215 0.05 consistent with the attributional model (Barrowclough and Hooley,
control-Patient 2003), which posits that that relatives who perceive that patients are
Personal −0.131 0.21 0.078 0.43 guilty of their behaviours rather than these being a result of the illness,
control-Relative are more likely to be critical with them as a mechanism that attempts to
Personal blame- 0.249 0.02 0.112 0.28
Patient
produce a change on those behaviours. However, contrary to what was
Personal blame- −0.069 0.55 −0.124 0.26 expected, and in contrast with other previous studies in schizophrenia
Relative and FEP (Hooley and Campbell, 2002; McNab et al., 2007; Vasconcelos
Emotional 0.163 0.13 0.587 0.000 et al., 2013; Wasserman et al., 2012), EOI was not associated with self-
representation
blame attributions and the attribution of control by the patient was not
related with criticism. It might be that in early stages of the disorder
Abbreviations: ARMS: At-Risk Mental State; FEP: First-Episode Psychosis; EE: Expressed Emotion; EOI: Emotional

Over-Involvement; SCL-90-R: Symptom Checkllist-90-Revised; IPQS-R: Illness Perception Questionnaire for

Schizophrenia-Relatives' version.
Significant at p < 0.05 (two-tailed) are bolded.
their perception of the illness.
As for the association of EE with distress, both criticism and EOI
were strongly related to anxiety and depression, which may be
interpreted as early psychosis having an important impact on relatives'
emotional state, provoking feelings such as concern, burden, distress
and sadness (Álvarez-Jiménez et al., 2010). In terms of the association
between EE and illness attributions, findings indicated that EE was
related to a perception of a cyclical/episodic pattern of the disorder
over time, probably because of the unstable nature of the early
psychosis stages in general, and more specifically in the ARMS stage
as referred to above. Interestingly, both criticism and EOI were related
to attributions of negative consequences for both patients and relatives
themselves, suggesting that EE seems to be associated with worry and
concern about the patient as well as with a sense of negative impact of
the disorder in relatives' own life. This finding is consistent with some
previous research in early psychosis. On the one hand, it might be
self-blaming cognitions were not already related to EOI because
relatives were dealing with feelings of concern resulting from the
emotional shock of disorder onset (in the case of FEP-relatives) and
with uncertainty about the diagnosis (in the case of ARMS-relatives),
more than with feelings of self-sacrifice or over-protection that
characterize self-blame. In addition, the negative emotional represen-
tation of the disorder was highly and strongly related with EOI,
supporting the idea that over-involved attitudes may be driven by
negative emotional responses towards patient's mental health pro-
blems in these early psychosis stages (McNab et al., 2007; Álvarez-
Jiménez et al., 2010). Moreover, the lack of association between
criticism and control-patient appraisals could be due to the prevalence
of lower levels of criticism in this sample.
In addition, criticism was associated with causal attributions,
negative emotions towards the disorder (emotional representation)
and lack of understanding of patients' problems (illness coherence),
indicating that, in the absence of adequate information and under-
standing of the disorder, relatives are likely to react with criticism
(Weisman et al., 1998). Thus, relatives who were more critical seemed
to have a poorer understanding of the patients’ situation and more

327

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T. Domínguez-Martínez et al.
negative emotions towards the disorder, which should probably be
understood in the context of the lack of a clear definition of ARMS'
patients' situation, the uncertain outcome of FEP patients and relatives'
confusion. Moreover, in line with previous studies indicating that
relatives attribute the cause of incipient psychosis to stress manage-
ment difficulties and interpersonal stress (Clarke and Couchman,
2012), we found that relatives tend to believe that the disorder was
caused by patient's stress or worry, as well as for thinking too much
about things. ARMS-relatives believed that patients’ personality and
attitudes (e.g., thinking about life negatively) were causes of their
problems, supporting the idea that relatives may particularly view
prodromal symptoms as related to difficulties in negotiating the normal
tasks of adolescence, rather than being symptoms of an emerging
psychosis (Lay et al., 2000).
Differences between ARMS and FEP relatives on the associations of
EE components with distress and illness attributions were found only
for the association between anxiety and EE indices. Anxiety was more
strongly related to criticism in ARMS-relatives than in FEP-relatives,
and it was associated with EOI in ARMS but not in the FEP group,
probably because ARMS-relatives were more concerned, distressed and
had more uncertainty about the patient's problems than FEP-relatives.
Regarding predictors of EE, relatives' criticism was predicted by
levels of both anxiety and depression as well as by attributions of blame
toward the patient, indicating that in early stages of psychosis relatives'
criticism is highly influenced by feelings of worry, distress, sadness or
despondency along with beliefs that the patient is responsible of his/
her behaviour. Also, EOI was predicted by relatives' negative emotional
representation of patients' problems, which is not surprising given the
commonality between EOI and emotional representation characteris-
tics. However, control-patient attributions did not predict criticism and
self-blame or self-control attributions did not predict EOI. The latter
seems to be inconsistent with the attributional model of schizophrenia,
but agrees with some previous research in these early stages of
psychosis (Domínguez-Martínez et al., 2014). On the one hand,
blame-patient attributions seem to have more influence than control-
patient attributions on relatives' critical attitudes. It might be that
attributions of blame, possibly highly emotionally-driven, in the very
early course of the disorder develop into beliefs of control in further
stages. On the other hand, this would link to the above-said about the
specific characteristic of EOI in early stages of the disorder. Finally, an
unexpected finding was that control-patient attributions predicted EOI
over and above distress variables. It seems likely though that control-
patient attributions in this early psychosis sample could be interpreted
as a feeling that the patient is powerless (Rexhaj et al., 2013),
explaining in part that relatives reacted with intrusive attitudes (EOI)
in order to help them to gain control over symptoms/behaviours. This
would be related with findings of Van et al. (2001) who have noted that
EOI has been associated with greater participation in care and more
attention to needs that are unmet by the treatment system.
Some limitations of the present study must be considered. First,
given the correlational nature of the study, it is not possible to establish
conclusions in terms of causality when interpreting the results. Second,
the measure of EE omits the positive aspects of this construct.
Preliminary research highlights the importance of warmth not only in
schizophrenia (López et al., 2004; Medina-Pradas et al., 2013), but also
in early stages of psychosis (Lee et al., 2014). In fact, the protective
effects of warmth associated with optimal levels of family involvement
seem to be already relevant in predicting functional improvement in
ARMS patients (Schlooser et al., 2010). Therefore, future research
should focus on understanding the antecedents of warmth, resilience
and protective aspects that characterize low-EE environments, and
apply EE measures that include warmth (Medina-Pradas et al., 2011,
Medina-Pradas, 2016 ).
328
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Psychiatry Research 247 (2017) 323–329
5. Conclusions
In conclusion, relatives' distress and illness attributions are already
strongly associated with levels of EE-criticism and EE-EOI in the early
stages of psychosis. This supports the idea that, similar to findings in
schizophrenia, relatives' emotional state and cognitive representations
of (pre)-psychosis are strongly linked to their emotional responses
towards the patient's disorder at the at-risk and onset stages of
psychosis. In addition, the attributional model of EE that
Barrowclough and Hooley (2003) established based on schizophrenia
samples seems to require some reformulation when considering the
early stages of psychosis in light of the present findings. It would be
interesting to extend this model by accommodating the differences
related to the various stages which patients and their families go
through along the psychosis continuum, although more research would
be necessary to ground such disorder-stages approach. This study
supports the importance of providing targeted family interventions to
early psychosis individuals and their caregivers. The negative emo-
tional and attributional consequences of relatives’ lack of understand-
ing of psychosis (by definition in the ARMS stage) highlight the need to
(i) offer them proper information about psychotic symptoms in
accordance with the stage of the disorder, and (ii) tailor psychological
interventions to help them handle difficult thoughts, appraisals and
emotions so that relatives can cope and adequately address the
challenges of the disorder over time, always considering the fact that
psychotic disorder is not necessarily the final outcome. Furthermore,
family intervention needs to focus on identifying beliefs about psycho-
sis in the treatment process, especially when relatives are dealing with
the emergence of a psychotic disorder, with the purpose to reduce their
negative appraisals, distress, high-EE attitudes and difficulties related
with the caring role before they become well-established.
Funding and other support
This study was supported by Ministerio de Economía y
Competitividad: Plan Nacional de I+D PSI2014-54009-R and Red de
Excelencia PSI2014-56303-REDT (PROMOSAM: Investigación en
Procesos, Mecanismos y Tratamientos Psicológicos para la Promoción
de la Salud Mental), Fundació La Marató de TV3 (091110), and
Generalitat de Catalunya (Suport als Grups de Recerca
2014SGR1070). NBV is supported by the Acadèmia Research Award
from the Catalan Government (Institució Catalana de Recerca i Estudis
Avançats, ICREA).
Conflict of interest
None.
Acknowledgments
The authors greatly appreciate the contributions done by clinicians
from the Fundació Sanitària Sant Pere Claver and the support offered
by this institution, and thank the families who participated in the
study.
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