Patients' perception of emotions in eating disorders and schizophreniaan investigation of a dyadic view of expressed emotion, emotional theory of mind, and measurement issues

Resumen

This thesis, presented as a compendium of published articles, is focused on the experience of emotions and affect by patients with a severe and chronic mental disorder, in particular with long-standing ED or schizophrenia. Matters like perception of EE, eToM, positive affect, and stress are indeed highly relevant in mental health and essential within the adult psychopathology. As seen, this kind of patients shows important difficulties perceiving emotions and affect in others, although it would be necessary to specify some questions a little more, especially in ED patients. These difficulties are thought to be related to each type of symptoms at a specific way and also act in detrimental to their social and family functioning. Research on emotions is not easy to approach scientifically, since it is a complex and broad topic. Hence, this thesis tried to make an advance in the understanding and measuring of the phenomenon from a rigorous approach. It is well-demonstrated that family EE is a factor with an elevated power predicting relapse in different psychiatric disorders and chronic diseases in general. The theoretical supposition is that this influence is due to the stress that it provokes in the patients. Thus, this thesis addressed to further investigate the transactional mechanism by which EE acts. Patients were asked directly for how they appraised the EE of their relatives and how much stress they felt subsequently. Although most studies of EE have used the objective measure of caregiver's actual criticism and EOI (the CFI), there is a small but growing literature examining patient's perception of caregiver's EE, particularly the patient's perception of their caregiver's level of criticism. It was thought that including both measures of caregivers' actual level of their criticism and EOI and patients' perceptions of their caregivers' emotional stance would enrich the understanding of the role of family processes and the course and treatment of the disorders. Doing so would provide a balanced assessment of the dyad, not just the caregiver's or patient's perspective, and would allow to compare both perspectives as well. Moreover, by examining both perspectives it would be possible to examine which one (relatives' or patients') is associated with symptoms as well as how specific index of EE is particularly related to clinical severity. Miklowitz (2004) said that the nature and stability of the bidirectional effects between patient and relative depend on dynamic processes in the patient, the relative, and their relationship. In this thesis, further research to fully comprehend the pathways from EE to patients' outcomes, and viceversa, was intended. In addition to examining the patients' appraisals of EE, it was also studied the patients' perceived stress associated with those appraisals. Previous research of the relationship between stress and psychopathology have almost not taken into consideration an individual's appraisal of the meaning and potential impact of family EE or characteristics of the individual and their illness that might mediate any relationship that does exist. For that, this thesis purposed to create a new instrument to assess perceived stress due to each specific EE index and to investigate how this stress associates with the different perspectives of EE and with the different symptoms. Another aspect is that traditionally, only the negative affect has been considered in EE studies despite some of the EE pioneers (f.i. Leff and Vaughn, 1985) declared that positive affect (in concrete, warmth) is as important as criticism and EOI. Moreover, the protective role hypothesized for warmth is being already preliminary demonstrated. However, no adequate instruments are available for this purpose. Therefore, another aim for this thesis emerged. That was to develop a new and psychometrically sound measure for perceived EE that included warmth. In this way, the specific associations between not only perceived and expressed criticism and EOI with symptoms and stress but also between perceived and expressed warmth could be analysed. Future family interventions could also benefit of this dyadic view of the EE that considers the positive affect, obtaining so a more complete information and from different perspectives of the phenomenon. Besides, the new measure, if easy and short, could facilitate its use for clinical purposes. It could be even used as a thermometer of the family temperature, far from the costly and long CFI which use is almost only possible in research settings. At last, psychological research was undertaken for this thesis to detect ways in which patients perceived their most familial other's emotions in a more naturalistic context (by means of perceived EE), likewise they inferred unknown others' emotions by means of a laboratory task (the eToM task RME). How they experienced different valence of the emotions (positive, negative, or neutral) was also studied, by including systematically warmth in the study of EE and comparing it to the perception of criticism or EOI (negative affect), and considering the new classification of the RME items into positive, negative, and non-emotional cognitive states. To the best of our knowledge, Bellack, Mueser, Wade, Sayers, and Morrison (1992) were the only ones before that linked the study of EE as experience by patients (in schizophrenia in their case) together with their capacity of emotional recognition. Their findings were partially consistent with the hypothesis that the effects of EE are mediated by patients' social and emotional skills deficits. They concluded that schizophrenia patients' ability to cope with even mild negative affect was impaired, both from the EE and from the emotion recognition point of views. To sum up, the present thesis entailed new research intended to generate more knowledge about how patients with a chronic and severe mental illness experience emotions. The subject was approximated from two different frameworks: the EE theory, on the one hand, and the eToM within the social cognition, on the other. As regards the focus of interest, the starting point was more advanced for schizophrenia patients than for those with ED since previous research had been more prominent in schizophrenia compared to ED. The studies for the present thesis were carried out in public and private mental health centers in association with the Clinical and Health Psychology Department of the Authonomous University of Barcelona, and in collaboration with other international professionals. In concrete, the new and expanded Brief Dyadic Scale of Expressed Emotion (BDSEE) for patients was the fruit of a two-month working visit at the University of Los Angeles, California (UCLA, USA), together with Prof. Steven R. López. Moreover, the author of this thesis got a lot of background about EE theory during research stays in the Institute of Psychiatry, King's College of London (UK), with Prof. Elizabeth Kuipers and in the University of Manchester (UK), Division of Psychology, with Prof. Christine Barrowclough. The specific aims of this thesis were: 1. To develop new measurement for EE and stress due to EE, 2. To study patients' appraisals of EE, 3. To confirm high-EE as a stressful factor for patients, 4. To include the positive emotions in the study of EE, 5. To study patients' eToM ability as another form of emotion/affect perception, and 6. To further consider the question of the emotional valence, both in EE and in eToM. This thesis is composed by four articles published in JCR indexed journals. Each of them describes one empirical study focused on different aspects of the explained aims and in one of the two populations of interest, patients with an ED or with schizophrenia. Thus, the study 1 shows the development of an expanded measure for patients' appraisals of the criticism, EOI and warmth that their relatives express towards them, the BDSEE, and its validation in a sample of patients with ED. This study followed the steps carried out in another study in UCLA in which the author of this thesis participated (Keefe, López, Tiznado, Medina-Pradas, and Mendoza, submitted for publication). This UCLA study was a preliminary validation of the first version of the BDSEE in a sample with schizophrenia. Both of them also compared patients' and carers' perspectives of EE to see if they coincided. The study 2 compiled in this thesis presents other new measure, the Perceived Stress due to Expressed Emotion (PSEE), to evaluate patients' self-reported levels of stress as related to their caregivers' criticism, EOI and warmth. Additionally, it examines the associations of stress with the EE as perceived by the patients and as expressed by the caregivers' (assessed with the CFI). Likewise, this study analyses the association between the two views of EE (patients' and caregivers') and the stress with the ED symptoms severity. The study 3 compares schizophrenia patients' and relatives' views of criticism, it examines whether the presence of caregiver's warmth can make patients perceive less criticism, and it analyses the relationship of the caregiver's expressed emotions and the perceived criticism with the psychotic symptoms severity. Finally, study 4 investigates the eToM ability in a sample of patients with ED, considering all the diagnostic subtypes and the emotional valence question. A detailed description of the characteristics of each sample, of the clinical and psychological functioning, of the family emotional attitudes, the eToM and the EE instruments, as well as of the procedures and statistical analyses followed can be found in the correspondent papers. This thesis showed that the two views of EE (patients' and relatives') relate differently with the patients' levels of stress and with symptom severity; and they also have different associations depending on the disorder studied and the specific emotion considered. Final reflections just put emphasis on the importance of including positive emotions, patients' appraisals of EE and the new measures. In essence, we have to bear in mind the bidirectional and mutually influential cycles of interaction between relatives and patients in the EE process, that is, the dyadic view. The effect of EE would depend on the relative, the patient, as well as the relationship between them. Thus, the best way of approach its study is taking into account both parts in a circular way, as said Miklowitz (2004). Finally, as pointed in the model of Lazarus and Folkman (Lazarus, 1993), the subjective appraisals or the way of perceiving situations have often more importance than the objective circumstances itself. Important applications for clinical treatments, assessment, and future research are also drawn. ARTICLES THAT COMPOUND THE PRESENT THESIS: Medina-Pradas, C., Navarro, J.B., López, S.R., Grau, A., Obiols, J.E. (2011). Further development of a scale of perceived expressed emotion and its evaluation in a sample of patients with eating disorders. Psychiatry research, 190, 2-3, 291-296. Medina-Pradas, C., Navarro, J.B., López, S.R., Grau, A., Obiols, J.E. (2011). Dyadic view of expressed emotion, stress, and eating disorder psychopathology. Appetite, vol. 57, 3, 743-748. Medina-Pradas, C., Navarro, J.B., Pousa, E., Montero, M.I., Obiols, J.E. (2012). Expressed and perceived criticism, family warmth, and symptoms in schizophrenia. The Spanish Journal of Psychology, 16, in press. Medina-Pradas, C., Navarro, J.B., Álvarez-Moya, E.M., Grau, A., Obiols, J.E. (2012). Emotional theory of mind in eating disorders. International Journal of Clinical and Health Psychology, 12 (2), in press.