Caregivers of persons with first-episode psychosis (FEP) often report high levels of distress. Preventing long-term or chronic distress within the whole family is an important focus of early intervention for psychosis. However, a more comprehensive understanding of the psychological factors involved is needed.
To examine the impact of subjective appraisals and expressed emotion on caregiver distress in FEP.
Within a cross-sectional design, 154 caregivers of 99 persons with FEP in a clinical epidemiological sample completed a series of questionnaires to examine potential predictors of caregiver distress.
Thirty-seven percent of caregivers were suffering from clinically significant distress. A linear mixed model analysis found that, after controlling for caregiver socio-demographic factors, service-user symptoms and global functioning, emotional over-involvement and subjective appraisal of caregiving were significant predictors of caregiver distress.
Caregiver distress is significant in the early phase of illness, and this seems to be more related to their subjective appraisal and over-involvement, than to variations in symptoms and global functioning of the person diagnosed with FEP. This lends further support to the stress-appraisal coping model and the cognitive model of caregiving in FEP, and highlights supportive interventions aimed at handling unhelpful cognitions and behaviors.
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Van Os J, Marcelis M, Germeys I, Graven S, Delespaul P (2001) High expressed emotion: marker for a caring family? Compr Psychiatry 42:504–507
Kuipers E, Bebbington P, Barrowclough B (2005) Research on burden and coping strategies in families of people with mental disorders: problems and perspectives. In: Leff J, Lopez J, Maj M, Okasha A (eds) Sartorius N. Families and mental disorder. From Burden to Empowerment, Wiley, pp 217–234
Addington J, Coldham EL, Jones B, Ko T, Addington D (2003) The first episode of psychosis: the experience of relatives. Acta Psychiatr Scand 108:285–289
Szmukler GI, Burgess P, Herrman H, Benson A, Colusa S, Bloch S (1996) Caring for relatives with serious mental illness: the development of the Experience of Caregiving Inventory. Soc Psychiatry Psychiatr Epidemiol 31:137–148
Martens L, Addington J (2001) The psychological well-being of family members of individuals with schizophrenia. Soc Psychiatry Psychiatr Epidemiol 36:128–133
Zubin J, Spring B (1977) Vulnerability: a new view of schizophrenia. J Abnorm Psychol 86:103–126
Leff J, Kuipers L, Berkowitz R, Eberlein-Vries R, Sturgeon D (1982) A controlled trial of social intervention in the families of schizophrenic patients. Br J Psychiatry 141:121–134
Kuipers E (2010) Time for a separate psychosis caregiver service? J Ment Health 19:401–404
Lazarus R, Folkman S (1984) Stress, appraisal, and coping. Springer, New York
Kuipers E, Onwumere J, Bebbington P (2010) Cognitive model of caregiving in psychosis. Br J psychiatry J Ment Sci 196:259–265
Barrowclough C, Lobban F, Hatton C, Quinn J (2001) An investigation of models of illness in carers of schizophrenia patients using the Illness Perception Questionnaire. Br J Clin Psychol 40:371–385
Wearden AJ, Tarrier N, Barrowclough C, Zastowny TR, Rahill AA (2000) A review of expressed emotion research in health care. Clin Psychol Rev 20:633–666
Hooley JM (2007) Expressed emotion and relapse of psychopathology. Annu Rev Clin Psychol 3:329–352
Butzlaff RL, Hooley JM (1998) Expressed emotion and psychiatric relapse: a meta-analysis. Arch Gen Psychiatry 55:547–552
Gleeson JFM, Cotton SM, Alvarez-Jimenez M, Wade D, Crisp K, Newman B, Spiliotacopoulos D, McGorry PD (2010) Family outcomes from a randomized control trial of relapse prevention therapy in first-episode psychosis. J Clin Psychiatry 71:475–483
Bird V, Premkumar P, Kendall T, Whittington C, Mitchell J, Kuipers E (2010) Early intervention services, cognitive-behavioural therapy and family intervention in early psychosis: systematic review. Br J psychiatry J Ment Sci 197:350–356
Linszen D, Dingemans P, Van der Does JW, Nugter A, Scholte P, Lenior R, Goldstein MJ (1996) Treatment, expressed emotion and relapse in recent onset schizophrenic disorders. Psychol Med 26:333–342
Breitborde NJK, López SR, Chang C, Kopelowicz A, Zarate R (2009) Emotional over-involvement can be deleterious for caregivers’ health: Mexican Americans caring for a relative with schizophrenia. Soc Psychiatry Psychiatr Epidemiol 44:716–723
Boye B, Munkvold OG, Bentsen H, Notland TH, Lersbryggen AB, Oskarsson KH, Uren G, Ulstein I, Lingjaerde O, Malt UF (1998) Pattern of emotional over involvement in relatives of patients with schizophrenia: a stress syndrome analogue? Nord J Psychiatry 52:493–499
Alvarez-Jiménez M, Gleeson JF, Cotton SM, Wade D, Crisp K, Yap MBH, McGorry PD (2010) Differential predictors of critical comments and emotional over-involvement in first-episode psychosis. Psychol Med 40:63–72
Patterson P, Birchwood M, Cochrane R (2005) Expressed emotion as an adaptation to loss: prospective study in first-episode psychosis. Br J Psychiatry Suppl 48:s59–s64
Raune D, Kuipers E, Bebbington PE (2004) Expressed emotion at first-episode psychosis: investigating a carer appraisal model. Br J Psychiatry 184:321–326
Petersen L, Jeppesen P, Thorup A, Abel M-B, Øhlenschlaeger J, Christensen TØ, Krarup G, Jørgensen P, Nordentoft M (2005) A randomised multicentre trial of integrated versus standard treatment for patients with a first episode of psychotic illness. BMJ 331:602
McGuffin P (1991) A polydiagnostic application of operational criteria in studies of psychotic illness. Arch Gen Psychiatry 48:764
Goldberg D, Williams P (1988) A user’s guide to the General Health Questionnaire. NFER-Nelson, Windsor
Huppert FA, Walters DE, Day NE, Elliott BJ (1989) The factor structure of the General Health Questionnaire (GHQ-30). A reliability study on 6317 community residents. Br J Psychiatry 155:178–185
Joyce J, Leese M, Szmukler G (2000) The experience of caregiving inventory: further evidence. Soc Psychiatry Psychiatr Epidemiol 35:185–189
Wiedemann G, Rayki O, Feinstein E, Hahlweg K (2002) The Family Questionnaire: development and validation of a new self-report scale for assessing expressed emotion. Psychiatry Res 109:265–279
Vaughn CE, Leff J (1976) The measurement of expressed emotion in the families of psychiatric patients. Br J Soc Clin Psychol 15:157–165
Magaña AB, Goldstein MJ, Karno M, Miklowitz DJ, Jenkins J, Falloon IRH (1986) A brief method for assessing expressed emotion in relatives of psychiatric patients. Psychiatry Res 17:203–212
Kay SR, Fiszbein A, Opler LA (1987) The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophr Bull 13:261–276
Santor DA, Ascher-Svanum H, Lindenmayer J-P, Obenchain RL (2007) Item response analysis of the Positive and Negative Syndrome Scale. BMC Psychiatry 7:66
Peralta V, Cuesta MJ (1994) Psychometric properties of the positive and negative syndrome scale (PANSS) in schizophrenia. Psychiatry Res 53:31–40
Bentsen H, Munkvold OG, Notland TH (1996) The interrater reliability of the Positive and Negative Syndrome Scale (PANSS). Int J Methods Psychiatr Res 6:227–235
APA (1987) Diagnostic and statistical manual of mental disorders (DSM-III-R). Washington DC
Leucht S, Kane JM, Kissling W, Hamann J, Etschel E, Engel RR (2005) What does the PANSS mean? Schizophr Res 79:231–238
Addington J, McCleery A, Addington D (2005) Three-year outcome of family work in an early psychosis program. Schizophr Res 79:107–116
Szmukler GI, Herrman H, Bloch S, Colusa S, Benson A (1996) A controlled trial of a counselling intervention for caregivers of relatives with schizophrenia. Soc Psychiatry Psychiatr Epidemiol 31:149–155
Tennakoon L, Fannon D, Doku V, O’Ceallaigh S, Soni W, Santamaria M, Kuipers E, Sharma T (2000) Experience of caregiving: relatives of people experiencing a first episode of psychosis. Br J Psychiatry 177:529–533
Barrowclough C, Parle M (1997) Appraisal, psychological adjustment and expressed emotion in relatives of patients suffering from schizophrenia. Br J Psychiatry 171:26–30
Hooley JM, Campbell C (2002) Control and controllability: beliefs and behaviour in high and low expressed emotion relatives. Psychol Med 32:1091–1099
Hooley JM, Hiller JB (2000) Personality and expressed emotion. J Abnorm Psychol 109:40–44
Jansen JE, Lysaker PH, Harder S, Haahr UH, Lyse H-G, Pedersen MB, Trauelsen AM, Simonsen E (2013) Positive and negative caregiver experiences in first-episode psychosis: emotional overinvolvement, wellbeing and metacognition. Psychol Psychother. doi:10.1111/papt.12014
Patterson P, Birchwood M, Cochrane R (2000) Preventing the entrenchment of high expressed emotion in first episode psychosis: early developmental attachment pathways. Aust N Z J Psychiatry 34:S191–S197
Heikkilä J, Karlsson H, Taiminen T et al (2002) Expressed emotion is not associated with disorder severity in first-episode mental disorder. Psychiatry Res 111:155–165
McNab C, Haslam N, Burnett P (2007) Expressed emotion, attributions, utility beliefs, and distress in parents of young people with first episode psychosis. Psychiatry Res 151:97–106
Jansen JE, Harder S, Haahr UH, Lyse H-G, Pedersen MB, Trauelsen AM, Simonsen E (2014) The role of metacognitions in expressed emotion and distress: a study on caregivers of persons with first-episode psychosis. Clin Psychol Psychother. doi:10.1002/cpp.1907
Bentsen H, Boye B, Munkvold OG et al (1996) Emotional overinvolvement in parents of patients with schizophrenia or related psychosis: demographic and clinical predictors. Br J Psychiatry 169:622–630
Cotton SM, McCann TV, Gleeson JF, Crisp K, Murphy BP, Lubman DI (2013) Coping strategies in carers of young people with a first episode of psychosis. Schizophr Res 146:118–124
Onwumere J, Kuipers E, Bebbington P, Dunn G, Freeman D, Fowler D, Garety P (2011) Coping styles in carers of people with recent and long-term psychosis. J Nerv Ment Dis 199:423–424
We are grateful to all of the patients and their caregivers who consented to participate, and to the clinicians in Opus Region Zealand, who provided access to their clients. The Region Zealand Health Scientific Research Foundation provided funding for this research, but had no involvement in the production of this paper.
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Jansen, J.E., Haahr, U.H., Harder, S. et al. Caregiver distress in first-episode psychosis: the role of subjective appraisal, over-involvement and symptomatology. Soc Psychiatry Psychiatr Epidemiol 50, 371–378 (2015). https://doi.org/10.1007/s00127-014-0935-8
- Emotional over-involvement
- First-episode psychosis