Family environment in early psychosisin search of the psychological mechanisms underlying the manifestation of expressed emotion in at-risk and onset stages of psychosis

Resumen

The way that a family has of reacting to and organizing itself around a psychotic condition has been found to have considerable influence on psychosis prognosis. The main aim of this thesis was to examine specific family environmental factors that have been demonstrated to be related with the course and outcome of psychotic disorders in the early stages of psychosis. The body of the thesis is divided in two main sections: a theoretical investigation and an empirical investigation. The theoretical investigation section includes one review of the current state of family research in At-Risk Mental State (ARMS) stage. The empirical investigation section includes three chapters investigating issues related to the measurement and validity of Expressed Emotion (EE) in daily life; the role of relatives’ insecure attachment dimensions as potential mediating factors in the association between relatives’ perceived loss and EE dimensions [criticism and Emotional Over-Involvement (EOI)]; and the potential mechanisms underlying the ontogenesis of EE by considering the contribution of both patients’ illness-related variables and relatives’ psychological factors. All the empirical studies were conducted with relatives of ARMS and First-Episode of Psychosis (FEP) patients who receive treatment and belong to the Sant Pere Claver- Early Psychosis Program (SPC-EPP). Chapter 1 describes a study investigating the real-life expression of EE by using the Experience Sampling Method. It was found that momentary criticism and EOI were respectively associated with criticism and EOI dimensions of the Family Questionnaire (FQ), thus supporting the criterion validity of momentary EE dimensions. Furthermore, findings showed that both momentary EE and FQ-EE dimensions were significantly associated with real-world experiences in the domains that are theoretically related to EE. Although criticism and EOI, as measured by momentary and psychometric self-reports, were expected to show a clearer differential pattern of relationships with daily appraisals and caregivers’ subjective states, these preliminary findings partly support the construct validity of momentary EE assessments and the construct and ecological validity of the FQ dimensions. Chapter 2 presents a study examining the relationships among relatives’ perceived loss, attachment styles, and EE as well as the mediating role of relatives’ attachment dimensions in the association between perceived loss and EE. Results showed that relatives’ perceived loss was associated with EE dimensions as well as with relatives’ attachment anxiety and avoidance. In addition, the current study indicated that relatives’ attachment anxiety mediated the relationship between perceived loss and EE, both for criticism and EOI attitudes. Chapter 3 examines whether relatives’ psychological distress and subjective appraisals of the illness predicted EE over-and-above patients’ illness characteristics. Findings indicated that relatives’ increased levels of anxiety and negative illness attributions predicted criticism and EOI at both baseline and follow-up assessments over-and-above patients’ poor clinical and functional status. In conclusion, the studies presented in this thesis emphasize the relevance of examining the role of relatives’ perceived loss, subjective appraisals of the illness as well as relatives’ emotional distress to unravel the psychological mechanisms underlying the early manifestation of EE attitudes. Moreover, they indicate that relatives’ attachment styles are relevant to understand how appraisals of loss might impact the formation of EE in the critical stages of the disorder. Finally, they underscore the importance of using novel techniques for investigating the daily life expression of EE. Overall, this work contributes to a better knowledge concerning the expression of family risk factors at the most vulnerable stages of psychosis, and therefore this would benefit family intervention programs in early psychosis.