Predicting the longitudinal effects of the family environment on prodromal symptoms and functioning in patients at-risk for psychosis

Article (PDF Available)inSchizophrenia Research 118(1-3):69-75 · February 2010with26 Reads
DOI: 10.1016/j.schres.2010.01.017 · Source: PubMed
Abstract
The current study examined the relationship between the family environment and symptoms and functioning over time in a group of adolescents and young adults at clinical high risk for psychosis (N=63). The current study compared the ability of interview-based versus self-report ratings of the family environment to predict the severity of prodromal symptoms and functioning over time. The family environmental factors were measured by interviewer ratings of the Camberwell Family Interview (CFI), self-report questionnaires surveying the patient's perceptions of criticism and warmth, and parent reported perceptions of their own level of criticism and warmth. Patients living in a critical family environment, as measured by the CFI at baseline, exhibited significantly worse positive symptoms at a 6-month follow-up, relative to patients living in a low-key family environment. In terms of protective effects, warmth and an optimal level of family involvement interacted such that the two jointly predicted improved functioning at the 6-month follow-up. Overall, both interview-based and self-report ratings of the family environment were predictive of symptoms and functioning at follow-up; however patient's self-report ratings of criticism had stronger predictive power. These results suggest that the family environment should be a specific target of treatment for individuals at risk for psychosis.
Predicting the longitudinal effects of the family environment on prodromal
symptoms and functioning in patients at-risk for psychosis
Danielle A. Schlosser
a,
, Jamie L. Zinberg
a
, Rachel L. Loewy
b
, Shannon Casey-Cannon
c
,
Mary P. O'Brien
a
, Carrie E. Bearden
a
, Sophia Vinogradov
b
, Tyrone D. Cannon
a
a
University of California at Los Angeles, 300 Medical Plaza, Box 666824, Los Angeles, CA. 90095, United States
b
University of California at San Francisco, 401 Parnassus Ave, Box 0984-PAR, San Francisco, CA. 94143, United States
c
Alliant International University, 1 Beach Street, San Francisco, CA. 94133, United States
a r t i c l e i n f o a b s t r a c t
Article history:
Received 23 September 2009
Received in revised form 21 January 2010
Accepted 25 January 2010
Available online xxxx
The current study examined the relationship between the family environment and symptoms
and functioning over time in a group of adolescents and young adults at clinical high risk for
psychosis (N=63). The current study compared the ability of interview-based versus self-
report ratings of the family environment to predict the severity of prodromal symptoms and
functioning over time. The family environmental factors were measured by interviewer ratings
of the Camberwell Family Interview (CFI), self-report questionnaires surveying the patient's
perceptions of criticism and warmth, and parent reported perceptions of their own level of
criticism and warmth. Patients living in a critical family environment, as measured by the CFI at
baseline, exhibited signicantly worse positive symptoms at a 6-month follow-up, relative to
patients living in a low-key family environment. In terms of protective effects, warmth and an
optimal level of family involvement interacted such that the two jointly predicted improved
functioning at the 6-month follow-up. Overall, both interview-based and self-report ratings of
the family environment were predictive of symptoms and functioning at follow-up; however
patient's self-report ratings of criticism had stronger predictive power. These results suggest
that the family environment should be a speci c target of treatment for individuals at risk for
psychosis.
© 2010 Elsevier B.V. All rights reserved.
Keywords:
Expressed emotion
Family environment
Prodrome
Psychosis
Schizophrenia
Ultra high risk
1. Introduction
Schizophrenia and other forms of psychosis are chronic
and seriously disabling disorders. Available drug treatments
are palliative rather than curative and only address positive
symptoms, with little or no effect on negative symptoms and
functional impairment. In step with other chronic somatic
illnesses, such as diabetes and heart disease, researchers have
shifted focus to early intervention and prevention. In the eld
of schizophrenia, this focus has generated an emergent body
of research aimed at delaying or preventing fully psychotic
symptoms from developing through the identication of the
prodromal phase of illness. The prodrome to psychosis is
characterized by attenuated psychotic symptoms and/or a
family history of psychosis with functional deterioration
(Yung and McGorry, 1996). Such ultra high risk (UHR)
individuals have high rates of conversion to psychosis,
ranging from 3060% over approximately two years (Cannon
et al., 2008; Miller et al., 2002). As the identication of UHR
individuals improves, it is critical that studies focus on
intervention-sensitive factors that mitigate the risk of conver-
sion to psychosis.
Despite the strong contribution of genetics to the develop-
ment of psychosis, adoption studies have highlighted that the
family environment can also have a substantial impact on
Schizophrenia Research xxx (2010) xxxxxx
Corresponding author. Tel.: +1 310 825 3458; fax: +1 310 794 9517.
E-mail addresses: dschlosser@mednet.ucla.edu (D.A. Schlosser),
jzinberg@psych.ucla.edu (J.L. Zinberg), rloewy@lppi.ucsf.edu (R.L. Loewy),
scasey-cannon@alliant.edu (S. Casey-Cannon), maryobrien@cox.net
(M.P. O'Brien), cbearden@mednet.ucla.edu (C.E. Bearden),
sophia.vinogradov@ucsf.edu (S. Vinogradov), cannon@psych.ucla.edu
(T.D. Cannon).
SCHRES-04156; No of Pages 7
0920-9964/$ see front matter © 2010 Elsevier B.V. All rights reserved.
doi:10.1016/j.schres.2010.01.017
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Please cite this article as: Schlosser, D.A., et al., Predicting the longitudinal effects of the family environment on prodromal
symptoms and functioning in patients at-risk for psychosis, Schizophr. Res. (2010), doi:10.1016/j.schres.2010.01.017
outcomes (Tienari et al., 2003, 2006). Furthermore, Expressed
Emotion (EE), a measure of the family environment, is the
strongest psychosocial predictor of clinical and functional
outcome for individuals with schizophrenia (Butzlaff and
Hooley, 1998) an d a critical domain of intervention in
treatment studies (Miklowitz, 2004). The Camberwell Family
Interview (CFI; Leff and Vaughn, 1985), the gold standard
measure of EE, is a 12 h semi-structured interview that is
conducted with the patient's primary caregiver. The CFI is
designed to elicit family attitudes about the patient's behavior
and symptoms and is thought to reect the family emotional
environment and the interactions between family members
(Hooley, 2007). When rating the interview, family member
comments are rated to determine whether they represent
attitudes that reect ve different indices: hostility, emo-
tional overinvolvement (EOI), criticism, warmth, and positive
remarks. A rating of high-EE is made based on six or more
critical comments, or the presence of hostility, or a rating of 4
or more comments on an index of emotionally overinvolved
attitudes.
Criticism and hostility, both components of high-EE, have
consistently been linked to poor outcomes among patients
with schizophrenia (Butzlaff and Hooley, 1998). Research
ndings have demonstrated that 65% of patients wi th
schizophrenia relapse within one year while living in a
high-EE environment, compared to about 35% in low-EE
environments (Butzlaff and Hooley, 1998; Kavanagh, 1992).
Despite the consistent ndings of high-EE having high
predictive validity, the results of studies examining how
EOI, one of the components of a high-EE environment, relates
to outcomes have been mixed. For instance, EOI predicted
negative clinical outcomes among patients with chronic
schizophrenia (Miklowitz et al., 1983) and positive clinical
outco mes with patients at imminent risk for psychos is
(O'Brien et al., 2006). In the early stages of developing the
criteria for EE, warmth in conjunction with EOI was observed
to have a positive effect on patients, but this nding has not
been empirically tested (Leff and Vaughn, 1985). Due to the
inconsistency of how EOI relates to outcomes, EOI was not
included in the rating of high-EE status for the purposes of
this study. Instead, EOI was analyzed independently and in
relation to warmth to highlight how EOI operates in a UHR
population.
In addition to testing the effect of EE on outcomes, the
current study examined patient and parent self-reported
perceptions of criticism and warmth in the family environ-
ment. Self-report ratings of perceived criticism and warmth
were assessed in order to determine whether there was a
signicant difference between interview-based versus self-
report ratings of the family environment and their compar-
ative impact on outcomes. This is the rst study to date to
examine the effects of interview-based (e.g. CFI measured EE
ratings) versus self-report (e.g. patient perceptions of
criticism) ratings of the family environment and their relative
effects on outcomes in a population at high risk for psychosis.
The current study hypothesized that:
1) High-EE families will signicantly differ from low-EE
families, such that:
(a) high-EE family members will report higher mean levels
of
how critical they are and lower mean levels of their own
expressions of warmth.In addition, (b) patients living in
high-EE environments will report higher mean levels of
perceived criticism from their primary caregiver, and lower
mean levels of perceived warmth.
2) A matched sample based on EE status, symptoms, and
functioning, as measured at baseline, will report signi-
cantly different levels of symptoms and functioning at
follow-up, such that patients living in high-EE family
environments will report more severe symptoms and
worse functioning at the 6-month follow-up, relative to
the low-EE sample.
3) Interview-based ratings of the family environment (e.g. CFI)
and self-report ratings (patient and family perceptions of
criticism and warmth) of the family environment at
baseline will BOTH be predictive of a change in symptoms
and functioning at follow-up, such that higher levels of
criticism and lower levels of warmth will be predictive of
worse symptoms and functioning at follow-up.
4) Emotional overinvolvement and warmth will interact,
such that moderate levels of EOI in the presence of warmth
will be predictive of better functioning at follow-up.
2. Method
2.1. Participants
Sixty-three outpatient participants, age 12 to 35, were
recruited to participate in the study from individuals already
enrolled in one of two prodromal research clinics: the Staglin
Music Festival Center for the Assessment and Prevention of
Prodromal States (CAPPS) at the University of California, Los
Angeles and the Prodromal Assessment, R esearch and
Treatment (PART) study at the University of California, San
Francisco. An inclusion criterion for the CAPPS and PART
studies was met by resea rch diagnos tic criteria for a
prodromal syndrome, as dened by the Structured Inter-
view for Prodromal Syndromes (SIPS; Miller et al., 2002). A
prodromal syndrome is dened by: 1) attenuated positive
symptoms, 2) brief, intermittent psychotic symptoms OR 3)
decline in role functio ning AND either a diagnosis of
schizotypal personality disorder or a rst-degree relative
with a psychotic disorder. The current study also included
subjects with recent-onset (e.g. within the past 3 months)
symptoms that reached a psychotic intensity but did not
reach criteria for a DSM-IV diagnosis of a psychotic disorder
such as schizophrenia, schizophreniform or schizoaffective
disorder. See Table 1 for the distribution of subjects in each
prodromal syndrome.
The sample consisted of more males than females and was
ethnically diverse (Tab le 1). Fifty-six participants were
recruited to participate from CAPPS and seven participants
were recruited from PART. CAPPS and PART use the same
stringent inclusion criteria and both sites are held to high
reliability standards (ICCN .80). Twenty-four of the 63 sub-
jects were included in a previously published study regarding
family factors in a UHR population (O'Brien et al., 2006). Due
to the current study's focus on family factors, participants
were recruited if they had family members wh o had
consented to participate. Sixty-one participants had a family
member complete the CFI and rated perceptions of the family
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Please cite this article as: Schlosser, D.A., et al., Predicting the longitudinal effects of the family environment on prodromal
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environment, while the remaining two participants only
completed the self-report ratings of perceived criticism and
warmth. Of the 61 participants that participated in the CFI,
82% were mothers (N = 50), 16% fathers (N = 10), and 1.6%
other relatives (N =1; grandmother). The sample distribu-
tion of family members is representative of other studies that
examine the effects of EE (O'Brien et al., 2006; Weisman et al.,
1998).
2.2. Measures
The outcome measures used were prodromal symptom
severity, as measured by symptoms rated on the Scale of
Prodromal Symptoms during the Structured Interview for
Prodromal Syndromes (SOPS/SIPS; Miller et al., 2002); and
social/occupational functioning, as measured by the aggre-
gate score on the Strauss Carpenter Outcome Scale (SCOS;
Strauss and Carpenter, 1972). The family environmental
factors were measured by the CFI (Leff and Vaughn, 1985)
and self-report questionnaires surveying the patient percep-
tions of criticism (PC; Hooley and Teasdale, 1989) and
warmth (PW; Study authors' adaptation of Hooley and
Teasdale, 1989); and family member reported perceptions
of their own level of criticism (FMPC) and warmth (FMPW).
The SIPS assesses symptoms in four domains (positive,
negative, disorganized, and general symptoms) and rates
symptom severity on a 06 scale, with 0 representing the
absence of a symptom and 6 representing severe and
psychotic. When a positive symptom is in the 35 range of
severity that symptom is considered an attenuated psychotic
symptom. Individuals diagnosed with a prodromal syn-
drome are considered at imminent risk for psychosis.
2.3. Procedure
The data included in this study were collected from
participants in the CAPPS and PART studies. After an intake
that determined study eligibility, participants at both sites
completed assessment measures at baseline and 6 months.
All family factor assessments and patient surveys were
completed at baseline (e.g. CFI, PC, an d PW). Primary
caregivers completed the CFI interview before rating their
own level of criticism and warmth (FMPC and FMPW) during
the baseline clinical assessment. The CFI was administered
and rated by the rst author and two research assistants, who
had been trained to high standards of reliability on the
measure by an expert rater (Jamie Zinberg, M.A.). For training
purposes, ten videos were rated independently and followed
up with consensus meetings. Raters achieved very good
consistency reliability (ICC= .93). For the remainder of the
sample, two raters coded each CFI. In addition, CFI inter-
viewers and raters were blind to the ratings on the outcome
measures.
2.4. Data analysis technique
The following data analysis techniques are described to
provide some background to the statistical approaches used
to test the study hypotheses. In order to test the rst
hypothesis that high-EE fam ilies will signicantly differ
from low-EE families, independent sample t-tests were
conducted. Differences between the EE groups were tested
based on mean levels of perceptions of criticism and warmth
(e.g. PC, PW, FMPC, and FMPW).
In order to test the second hypothesis, a matched sample
of low-EE participants was generated to match the high-EE
participants. The matched sample was based on the high-EE
group's mean levels of baseline prodromal symptomatology,
baseline functioning, age, gender, and education. The
matched sample grouped patients within one standard
deviation of baseline symptoms and levels of functioning.
The purpose of using a matched sample technique was to
highlight the specic
effect of the family environment over
time by effectively controlling for a number of factors at
baseline. While a regression analysis could have been
conducted instead, entering all the matching variables into
the model would have resulted in a substantial loss of power.
Another benet of the matching technique is that it controls
for the variability (e.g. differences in symptom severity)
between the high and low-EE groups observed at baseline
and the unequal sample sizes between the high-EE (N=19)
and low-EE (N = 42) groups.
To test the third hypothesis, two sets of regression
analyses were conducted. The rst tested whether patient
perceived criticism and warmth were predictive of a change
in positive symptoms and functioning over time. Due to
baseline and follow-up symptoms being signicantly related
to one another, change scores were calculated to represent a
change in symptoms over time. The second regression
analysis tested whether the interview-based measure of the
family environment predicted change in positive symptoms
over time. CFI-rated hostility and criticism were entered into
the rst step and CFI-rated warmth was entered into the
second step. In order to determine whether self-report
measures were more or less predictive of symptoms and
functioning over time, beta weights and semi partial
correlation statistics are reported.
In order to test the fourth hypothesis to determine if EOI
and warmth interact to predict functioning over time, a
hierarchical regression analysis was used. In order to test if
moderate levels of EOI interact with warmth, two values of
EOI were created to reect a moderate (EOI = 3 based on a 05
scale) and a non-moderate level of EOI (EOI=0, 1, 2, 4, 5). The
Table 1
Characterization of study participants (N = 63).
Gender (N, %)
Male 41 (65.1%)
Female 22 (34.9%)
Age (mean years, SD) 15.89 (2.80)
Education (mean years, SD)
Father 12.98 (1.91)
Mother 13.17 (1.73)
Ethnicity (N , %)
Caucasian 34 (54%)
Latino/Hispanic 9 (14.3%)
African American/Black 10 (15.9%)
Asian American/Pacic Islander 2 (3.2%)
Other 8 (12.7%)
Prodromal Syndrome (N, %)
Attenuated positive symptom prodromal syndrome 50 (79.4%)
Brief intermittent psychotic symptom syndrome 4 (6.3%)
Genetic risk and deterioration prodromal syndrome 4 (6.3%)
Non specic psychotic syndrome 5 (8%)
3D.A. Schlosser et al. / Schizophrenia Research xxx (2010) xxxxxx
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moderate rating of EOI is based on the mean level of EOI in this
sample. The reason for creating an indicator variable that
represented EOI as either moderate or non-moderate was
based on the hypothesis that moderate levels of EOI represent
an optimal level of involvement whereas high and/or low
levels of EOI might be predictive of poor outcomes. Thus
participants were classied into moderate or extreme classi-
cation of EOI. The EOI classication was then entered into a
regression analysis to determine if moderate levels of EOI
interacted with warmth differently from non-moderate levels
of EOI. The regression analysis included the predictors of EOI
at a moderate level, CFI-rated warmth, and the interaction
term of moderate EOI × warmth. The results will be plotted
using the coefcients in the regression analysis. The outcome
variable was change in functioning over time, based on the
SCOS.
3. Results
3.1. Preliminary analyses
At baseline, about twice as many families were identied
as being low in EE (N= 42; 68.9% of the sample) than those
identied as meeting criteria for high-EE status (N =19;
31.1% of the sample). The distribution of high-and low-EE
individuals is consistent with the rates of EE identied in
previous studies with UHR and rst episode populations
(Hooley and Richters, 1995; O'Brien et al., 2006). Of the 19
family members identied as having high-EE attitudes, 13
exhibited hostility during the CFI. Over the course of the
study, 19 subjects converted to psychosis, reecting a 30%
conversion rate. Of the 63 patients, 59 had follow-up data.
Four subjects dropped out of the study, reecting a 6%
attrition rate.
Prior to running the main analyses, associations between
the outcome variables and demographic variables (gender,
age, ethnicity, and socioeconomic status) were assessed using
t-tests, one-way ANOVAs, and Pearson correlations. Analyses
were also run to determine if there were signicant
differences between the CAPPS and PART samples on
demographic variables, symptoms or functioning measures.
None of these analyses were signicant except for the
relationship between overall functioning (SCOS) at follow
up and age (r= .45, p= . 003). Therefore, age was used as a
covariate in subsequent analyses examining follow-up func-
tioni ng. In order to examine the relations hip between
interview-based and self-report ratings of the family envi-
ronment, Pearson correlation ana ly ses were conducted
(Table 2). Family member ratings of their own levels of
warmth (FMPW) were signicantly negatively related to CFI-
rated criticism (r = .40, p b .01) and signi
cantly positively
related
to CFI-rated warmth (r = .54, p b .01). Patient ratings
of perceived parental warmth were signicantly related to
the CFI-ratings of warmth (r=.52, p b .01).
3.2. Main analyses
The results of the rst hypothesis indicated that family
members rated as high in EE reported signicantly higher
mean levels of their own level of criticism and lower levels of
warmth ( Table 3). Unexpectedly, there were no signicant
differences in the mean level of patient reported perceptions
of criticism and warmth between high and low-EE families. A
chi-square test resulted in no signicant associations between
conversion to psychosis and EE status (χ²(1, N=61) = 1.74,
p=.19).
Results of the second hypothesis revealed signicant
mean differences in positive symptoms at follow-up, such
that patients from high-EE families had more severe positive
symptoms at follow-up relative to the patients from low-EE
families (Table 4). There were no signicant differences
between the high and low-EE groups in functioning as
measured by the SCOS at follow-up.
The results of the t hird hypot hesis were signicant
(R²=.21; p =.001) and indicated that perceived criticism
predicted 21% of the variance of change in positive symptoms
= .45; t = 2.80; pb .01 part r²=.21). In order to test if
this result might be related to the presence of suspicious
thinking, a Pearson correlation analysis was conducted. The
non-signicant result indicated that patient-perceived criti-
cism was not related to suspicious thinking at baseline, as rated
by the SIPS (r=.30, p =.06). Patient perceived warmth and
family member's perceptions of their own levels of criticism
and warmth did not signicantly predict a change in symptoms.
Self-report ratings of the family environment were not
predictive of functioning over time. The results, testing the
interview-based ratings of the family environment, were also
signicant. CFI-rated hostility and criticism ratings were
entered in the rst step and CFI-rated warmth was entered in
the second step. The results were signicant (R²=.17, p=.03)
and indicated that 15% of the variance in the change in positive
symptoms was predicted by hostility and 7% by criticism in the
Table 2
Pearson correlation analyses correlating interview-based (CFI rated criticism
and warmth) and self-report (perceptions of criticism and warmth) ratings
of the family environment.
CFI-criticism CFI-warmth
PC-Mother + father .10 .19
PW-Mother + father .25 .52**
FMPC .04 .11
FMPW .41** .54**
CFI-criticism 1 .40**
Note. PC = perceived criticism; PW = perceived warmth; FMPC = family
member perception of own level of criticism; FMPW = family member
perception of own level of warmth.
**pb .01.
Table 3
Results of independent sample t-tests testing the rst hypothesis that there
are signicant mean differences in patient and family perceptions of criticism
and warmth, between the high and low-EE groups. (N= 61)
High-EE mean
(SD)
Low-EE mean
(SD)
t-statistic
PC-Mother + father 8.92 (6.02) 10.39 (5.20) .802
PW-Mother + father 10.46 (4.41) 13.82 (6.22) 1.749
FMPC 6.25 (2.05) 4.87 (1.89) 2.093*
FMPW 7.33 (1.88) 8.87 (1.36) 2.958**
Note. PC = perceived criticism; PW = perceived warmth; FMPC = is the
family member's perception of his or her own level of criticism; FMPW = the
family member's perception of his or her own level of warmth.
*pb 0.05; **pb .01.
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Please cite this article as: Schlosser, D.A., et al., Predicting the longitudinal effects of the family environment on prodromal
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family environment =.42; t= 2.52; pb .01 part r²=.15;
ß= .34; t= 2.03; pb .05 part r²=.07). Warmth, however,
did not signicantly add to the predictive model of follow-up
symptoms.
The results of the fourth hypothesis were signicant and
provided evidence for the interactive effect of EOI and
warmth on predic ting functioning over time (Table 5;
Fig. 1). EOI and warmth did not independently predict
functioning, however; the interaction effect was signicant
= 3.90; t = 2.90; p =.006). The interaction term plotting
moderate levels of EOI and warmth was signicant, however,
there was not a signi cant relationship between non-
moderate levels of EOI and warmth, as can be seen in the
gure based on the at regression line representing the non-
moderate value of EOI. The model tested provided evidence
for the moderating effects of warmth on the relationship
between a moderate level of EOI and changes in functioning
over time. Specically, those participa nts who reported
relatively higher levels of warmth were more likely to
experience improved changes in functioning when EOI was
at an optimal (e.g. moderate) level. Those participants who
reported relatively lower levels of warmth were likely to
experience a similar change in functioning regardless of the
level of EOI.
4. Discussion
This study tested the longitudinal effects of the family
environment on symptoms and functioning in individuals at
high clinical risk for psychosis. The results identied the
specic impact of high-EE on positive attenuated psychotic
symptoms, such that patients living in high-EE environments
exhibited worsening positive symptoms over time compared
to those living in low-EE environments . This nding is
particularly important considering that worsening positive
symptoms signal the conversion from the prodrome to
psychosis. This result was further supported when criticism
and hostility, factors of high-EE, were found to be signicantly
predictive of a change in positive symptoms over time. One
explanation for this nding might be that if a patient is living
in a hostile family environment, it is likely a stressful
experience for him/her and that stress could be the
mechanism that accounts for the worsening of the high-risk
symptoms over time.
Another important nding was the interactive relation-
ship between EOI and warmth and its joint impact on
improving functioning over time. Typically, EOI has been
associated with negative outcomes and the only other study
that examined the family environment in a UHR sample
suggested that EOI had a positive effect on outcome (O'Brien
et al., 2006
). The current study helps to clarify that seeming
c
ontradiction . EO I can act as a protective factor when
exhibited at moderate levels and within the context of
warmth. Emotionally warm and moderately involved parents
may play a role in the patient's improved functioning by
mitigating the patient's experience of stress. There may be an
optimal level of parental emotional involvement that is
neither too distant nor too enmeshed, that provides appro-
priate social support for this age group.
The analyses comparing the effects of interview-based
versus self-report ratings of the family environment on
outcomes provided some interesting ndings. The current
study found that both in te rview-based and self-report
measures of the family environment were predictive of
changes in positive symptoms over time. By examining the
Beta wei ghts and the semi partial correlations, patient
perceptions of criticism were more predictive of changes in
positive symptoms over time than the CFI-r ated family
factors. This nding is consistent with the Hooley and
Teasdael (1989) study with a sample of depressed patients,
which found that p atient-perceived criticism was more
predictive of symptoms than the CFI criticism scale. The
clinical utility of such a brief measure of family attitudes that
has yielded strong predictive value of clinical outcomes has
considerable implications for patients, families, and mental
health practitioners. Many clinicians may be aware of the
important rol e of family criticism in the psychosocial
outcome of UHR patients and those with schizophrenia, but
identifying high rates of criticism is far easier with a brief
patient report questionnaire than with the CFI, which is time
consuming to administer and code. By using the very brief PC
questionnaire, clinicians could efciently identify patients
whose family environments might put them at elevated risk
for symptom exacerbation.
5. Limitations
The current study was limited by a relatively small sample
size, which restricted the type of analyses that could have
been conducted. For instance, structural equation modeling
would be a useful statistical approach to examine the effects
of family factors due to the ability to examine interactions in a
Table 4
Results of independent sample t-tests examining symptomatic and func-
tioning differences, between the EE groups based on a matched sample.
(N= 38)
High-EE
(mean, SD)
Low-EE
(mean, SD)
t-statistic
Positive symptoms 9.75 (3.22) 6.46 (3.69) 2.40*
Negative symptoms 10.25 (6.33) 9.92 (6.73) .125
Functioning 11.92 (.29) 11.23 (1.59) 1.47
Note. Functioning was measured by the Strauss Carpenter Outcome Scale. EE
status was measured based on 6 or more critical comments and/or the
presence of hostility.
*p b 0.05.
Table 5
Hierarchical regression analysis analyzing the family environment as it predicts
change in functioning, as measured by the Strauss Carpenter Outcome Scale.
R² F R² adjR² B SEB ß part r²
Step1 .000 .000 .000 .026
EOI .007 .354 .003 .00
Step 2 .027 1.05 .027 .024
Warmth .458 .447 .191 .03
Step 3 .134* 4.59 .107 .064
EOI× warmth .716 .334 1.67* .11
Note. EOI = Emotional family environment; EOI ×warmth = the interaction
term of EOI by warmth. A change statistic was calculated representing a
change from baseline to the 6-month follow-up functioning, as measured by
the Strauss Carpenter Outcome Scale.
*p b .05.
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more rigorous way. The small sample size also limited the
power to detect if the family environment is predictive of
conversion to psychosis. In order to further identify factors in
the family environment that increase clinical risk, it is critical
to have a large sample size with complete follow-up data,
preferably with multiple time points.
6. Future directions
The ndings in the current study have signicant clinical
implications as well as indications for future research. In
terms of future research studies, it would be benecial to test
if the ndings from the current study are maintained over
longer periods of fo llow-up. In addition, more complex
models are warranted to examine the possible interactive
effects of the family environment and biological risk factors.
Due to the signicant effect of family factors on prodromal
symptoms and functioning, it would be in teresting to
examine whether those same variables are predictive of
conversion to psychosis in a larger sample. Furthermore, it
would be benecial to examine possible neurobiological
characteristics in patients (e.g. dysregulation of cortisol)
that might make particular individuals more vulnerable or
protected from stress in the family environment.
From a clinical perspective, family members should be
informed about the results of the c urrent study. It is
important to note that when communicating the results of
the current study and additional research ndings regarding
the possible effects of the family environment on symptoms
and functioning, it is critical to avoid imposing blame on
family members. This can be a ne line to walk with families.
At the same time of explaining that they did not cause the
symptoms or difculty with functioning, they are told that
they can still affect these outcomes in their loved one. To start,
family members should be informed that they could play a
protective role for their relative who is at high clinical risk for
developing psychosis. In particular, family members should
be informed of the importance of maintaining a low-key
home environment. Examples that describe the aspects of a
low-EE environment could be shared with families. In
addition, it could be benecial if family mem bers are
informed of the importance of combining appropr iate
protectiveness and concern with warmth, as this led to
improved functioning in the current study. Future research
studies should test the efcacy of providing this type of
psychoeducation to families.
Role of funding source
This research was supported by the following grants: NARSAD Young
Investigator Award (MPO), NARSAD Young Investigator Award (CEB), NIMH
MH65079 (TDC), NIMH MH066286 (TDC), as well as donations from the
Rutherford Charitable Foundation and Staglin Music Festival for Mental
Health (TDC), and a gift by the Lazslo N. Tauber Family Foundation. The
funding sources had no further role in study design; in the collection,
analysis and interpretation of data; in the writing of the report; and in the
decision to submit the paper for publication.
Contributors
Dr. Schlosser designed the study, wrote the protocol, managed the
literature searches, undertook the statistical analysis, and wrote the rst
Fig. 1. Moderating effects of warmth on the relationship between a moderate level of emotional overinvolvement (EOI) and change in functioning over time.
6 D.A. Schlosser et al. / Schizophrenia Research xxx (2010) xxxxxx
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Please cite this article as: Schlosser, D.A., et al., Predicting the longitudinal effects of the family environment on prodromal
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draft of the manuscript. All authors contributed to and have approved the
nal manuscript.
Conict of interest
All authors declare that they have no conicts of interest.
Acknowledgments
We would like to thank the research assistants who coded the CFI's and
administered the outcome measures.
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    • "For example, it is possible that perceptions of parent-child relationships are impaired among CHR youth, but not among help-seeking controls, due to the presence of emerging positive symptoms (e.g., less accurate in interpreting social interactions, more distrustful of others). Although other studies have found that CHR youths' perceptions of the family environment may more strongly predict outcome than clinician-rated interviews (Schlosser et al., 2010), research should evaluate whether parent reports, laboratory observation, or standardized clinician ratings of the family environment differentially predict scores on self-reported social stress among youth with versus without CHR. Such studies may clarify the extent to which CHR youth are uniquely affected by parentchild relationships or are affected by their subjective perceptions of these relationships (Fig. 1). "
    [Show abstract] [Hide abstract] ABSTRACT: Stress is related to symptom severity among youth at clinical high-risk (CHR) for psychosis, although this relation may be influenced by protective factors. We explored whether the association of CHR diagnosis with social stress is moderated by the quality of parent-child relationships in a sample of 96 (36 CHR; 60 help-seeking controls) adolescents and young adults receiving mental health services. We examined self-reported social stress and parent-child relationships as measured by the Behavior Assessment System for Children, Second Edition (BASC-2), and determined CHR status from the clinician-administered Structured Interview for Psychosis-Risk Syndrome (SIPS). The social stress subscale, part of the clinical domain of the BASC-2, assesses feelings of stress and tension in personal relationships and the relations with parents subscale, part of the adaptive domain of the BASC-2, assesses perceptions of importance in family and quality of parent-child relationship. There was a modest direct relation between risk diagnosis and social stress. Among those at CHR, however, there was a significant relation between parent-child relationships and social stress (b=-0.73, t[92]=-3.77, p<0.001, f(2)=0.15) that was not observed among non-CHR individuals, suggesting that a positive parent-child relationship may be a protective factor against social stress for those at risk for psychosis. Findings provide additional evidence to suggest that interventions that simultaneously target both social stress and parent-child relationships might be relevant for adolescents and young adults at clinical high-risk for psychosis.
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    • "Among the three components of EE, criticism is regarded as the principal component [17] and impacts negatively the course of psychotic illness. Receiving criticism from family members in the early stages of schizophrenia is known to be associated with the number of relapses and the severity positive symptoms over time [23] , and family criticism in patients with ARMS predicts an increase in positive symptoms over time [7] . Thus, it seems reasonable to investigate separately the link between criticism and relevant variables in the early phase of mental illness, to prevent the negative effect of criticism in this early stage. "
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    • "For example in the study by examining the role of self-esteem in psychosis, relatives' criticism (assessed using the CFI) was no longer predictive of negative evaluation of self when the service users' perceived negative evaluation from the relative (based on service user interview ratings) was included into the model. Similarly, in studies by Schlosser et al. (2010) and Lee et al. (2013), it is the service users' perception of criticism from the relative in at risk populations and perceived positive affect from relatives in early psychosis (respectively) which better predict subsequent outcome, rather than interview ratings of relationship quality. These findings could reflect a difference in relatives' actual behavior in situ, compared to that assessed by the CFI used to rate EE. "
    [Show abstract] [Hide abstract] ABSTRACT: Working with families in psychosis improves outcomes and is cost effective. However, implementation is poor, partly due to lack of a clear theoretical framework. This paper presents an interpersonal framework for extending the more familiar cognitive behavioral therapy model of psychosis to include the role of relatives’ behavior in the process of recovery. A summary of the framework is presented, and the evidence to support each link is reviewed in detail. Limitations of the framework are discussed and further research opportunities highlighted. Clinical implications and a case example are described to show how the framework can be used flexibly to facilitate clinical practice. Our aim is to shift the focus of psychosocial interventions from an individualistic approach to treatment, towards greater involvement of relatives and recognition of the importance of the social environment on mental health. Electronic supplementary material The online version of this article (doi:10.1007/s10608-015-9731-3) contains supplementary material, which is available to authorized users.
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