Perceived criticism from family members as a predictor of the one-year course of bipolar disorder
Introduction
Patients with bipolar disorder have high rates of relapse, high levels of intermorbid symptoms, and poor life functioning despite pharmacotherapy (e.g., Gitlin et al., 1995). A portion of the variability in patients' symptomatic outcomes can be attributed to psychosocial stressors, including life events (Johnson and Miller, 1997), low levels of social support (Johnson et al., 1999) and high levels of expressed emotion (EE) in caregivers (Miklowitz et al., 1988, O'Connell et al., 1991, Kim and Miklowitz, 2004, Yan et al., 2004). Notably, bipolar and unipolar depressed patients whose relatives express high levels of EE (criticism, hostility, or emotional overinvolvement) are at significantly greater risk for relapse over 9- to 12-month prospective periods than patients whose relatives express low levels of these attitudes. A meta-analytic review found a mean effect size of 0.45 (r statistic) for the EE/relapse association in six studies of patients with unipolar (three studies) and bipolar mood disorders (three studies; Butzlaff and Hooley, 1998).
Despite the consistency of EE as a prognostic indicator, the traditional methods for assessing EE are cumbersome and not well suited to large-scale community studies. Typically, EE is assessed through the Camberwell Family Interview (CFI; Vaughn and Leff, 1976), which takes h to administer and up to 3 h to code for each relative. Two promising alternatives have been proposed. The Five-Minute Speech Sample (FMSS; Magaña et al., 1986), in which the relative is asked to speak for 5 min about the patient and how well the two get along together, takes approximately 20 min to code. It has high reliability, convergent validity, and discriminant validity (e.g., Miklowitz et al., 1989, Stubbe et al., 1993), but data on its predictive validity are limited (Asarnow et al., 1994, Uehara, 1995). Furthermore, the FMSS has low sensitivity in identifying high-EE attitudes based on the CFI (Magaña et al., 1986, Miklowitz et al., 1989).
An even briefer alternative for measuring EE is the four-item self-report Perceived Criticism Scale (PCS; Hooley and Teasdale, 1989). Using 10-point Likert-type subscales, patients rate the severity of criticism they perceive from each relative (usually parents, spouse, or siblings) and the severity of their own criticisms toward this same relative. Later versions of the scale (White et al., 1998) included items measuring the patients' self-reported distress when criticized by relatives and patients' perceptions of how distressed their relatives become when criticized by the patients. This scale takes only 5 min to administer and code, which makes it particularly well suited to large-scale community-based studies.
Among patients with major depressive disorder, patients' PCS ratings of the severity of criticism expressed by spouses were stronger predictors of relapses over 9 months than CFI–EE ratings of spouses (Hooley and Teasdale, 1989). Among patients with obsessive–compulsive disorder or panic disorder with agoraphobia, higher patients' PCS ratings of relatives predicted poorer treatment outcomes above and beyond CFI–EE ratings (Chambless and Steketee, 1999, Renshaw et al., 2003). PCS ratings of spouses also predicted relapses among patients with substance abuse disorders (Fals-Stewart et al., 2001). In each of these studies, patients' ratings were independent of their symptoms when completing the PCS.
Thus, the PCS has promise as a brief, prognostically valid measure of family tension. Its predictive validity in bipolar disorder, however, has not been examined. Using longitudinal data from a large multi-center outpatient sample (N = 360), we hypothesized that patients with bipolar disorder who reported a higher severity of criticisms from relatives would have more severe manic and depressive symptoms and fewer days of mood stability over 1 year than patients who reported a low severity of criticisms. Secondly, because patients with bipolar disorder appear to be stress-sensitive (Post, 1992, Hammen and Gitlin, 1997, Johnson and Miller, 1997) and prone to dysfunctional attitudes and information-processing biases in response to negative stimuli (Lyon et al., 1999, Reilly-Harrington et al., 1999), we hypothesized that patients who reported feeling more upset by relatives' criticisms would have higher mood symptom scores and fewer days in recovery status over the study year. Finally, we predicted that patients' PCS ratings would predict their symptomatic outcomes independently of baseline symptom, illness history, or demographic variables.
Section snippets
Subjects
Subjects were 360 patients with bipolar disorder who were drawn from the first 1000 enrollees in the ongoing Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD; Sachs et al., 2003). STEP-BD is a multi-site community research program examining the course and treatment of bipolar disease. Data for the present study were based on the first longitudinal year of the STEP-BD Standard Care Pathway, in which patients were treated and followed using best-practice pharmacotherapy.
To
Differences between patients with and without PCS ratings
Of the first 1000 STEP-BD patients, 554 did not complete the PCS (55.4%). This high rate of missing data reflects that, early on in STEP-BD, many of the study sites placed more emphasis on completion of interview-based measures than questionnaire measures (for study details, see Sachs et al., 2003). Additionally, a temporary stoppage in the administration of the form at all sites led to missing data for 24 patients (2.4%), and 62 patients (6.2%) reported having no close relatives or friends.
Discussion
The emotional climate of the family or couple environment has significant prognostic value in the course of mood disorders (Butzlaff and Hooley, 1998). This study demonstrated that the emotional reactions of patients with bipolar disorder to criticisms from their relatives contributed to their liability to a more severe course of illness. A single rating of subjective distress in response to relatives' criticisms predicted patients' levels of depression and mania and their proportion of days in
Acknowledgements
This research project was funded in part by the National Institute of Mental Health (NIMH), National Institutes of Health, under Contract N01MH80001. Any opinions, findings, and conclusions or recommendations expressed in this publication are those of the authors and do not necessarily reflect the views of the NIMH. This article was approved by the Publication Committee of the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). Investigators for the STEP-BD are:
STEP-BD
References (37)
- et al.
Relapse among married or cohabiting substance-abusing patients: the role of perceived criticism
Behavior Therapy
(2001) - et al.
Five-factor personality traits in patients with seasonal depression: treatment effects and comparisons with bipolar patients
Journal of Affective Disorders
(1999) - et al.
Expressed emotion as a predictor of outcome among bipolar patients undergoing family therapy
Journal of Affective Disorders
(2004) - et al.
A brief method for assessing expressed emotion in relatives of psychiatric patients
Psychiatry Research
(1986) - et al.
Convergent and discriminant validity of perceived criticism from spouses and family members
Behavior Therapy
(1996) - et al.
Rationale, design, and methods of the systematic treatment enhancement program for bipolar disorder (STEP-BD)
Biological Psychiatry
(2003) - et al.
Expressed emotion versus relationship quality variables in the prediction of recurrence in bipolar patients
Journal of Affective Disorders
(2004) Diagnostic and Statistical Manual of Mental Disorders
(1994)- et al.
Family expressed-emotion, childhood-onset depression, and childhood-onset schizophrenia spectrum disorders: is expressed emotion a nonspecific correlate of child psychopathology or a specific risk for depression?
Journal of Abnormal Child Psychology
(1994) - et al.
Beck Depression Inventory-II
(1996)
Expressed emotion and psychiatric relapse: a meta-analysis
Archives of General Psychiatry
Expressed emotion and behavior therapy outcome: a prospective study with obsessive–compulsive and agoraphobic outpatients
Journal of Consulting and Clinical Psychology
The structure of expressed emotion: a three-construct representation
Psychological Assessment
Predicting expressed emotion: a study with families of obsessive–compulsive and agoraphobic outpatients
Journal of Family Psychology
Parental communication deviance and affective style: predictors of subsequent schizophrenia spectrum disorders in vulnerable adolescents
Archives of General Psychiatry
Structured Clinical Interview for DSM-IV Axis I Disorders
Relapse and impairment in bipolar disorder
American Journal of Psychiatry
A marital/family discord model of depression: implications for therapeutic intervention
Cited by (81)
Bipolar disorder and self-perceived interpersonal relationships in the family: A household cross-sectional study among married adults in Rajshahi city, Bangladesh
2021, Journal of Affective Disorders ReportsPerformance of a measure to assess distress in bipolar disorder
2020, Revista de Psiquiatria y Salud MentalPartner criticism during acute-phase cognitive therapy for recurrent major depressive disorder
2019, Behaviour Research and TherapyCitation Excerpt :These cognitive biases may increase the emotional impact of criticism from partners, and may also increase criticism of partners due to unfavorable views of the self and the partner, pessimism about the future, and less-effective coping behaviors. Consistent with these ideas, some studies suggested that patients' distress about criticism, rather than perception of criticism itself, may be more important in treatment outcomes (Miklowitz, Wisniewski, Miyahara, Otto, & Sachs, 2005; Steketee, Lam, Chambless, Rodebaugh, & McCullouch, 2007). Thus, our findings that perceived criticism and criticism of partners correlated with self-reported depressive cognitive content broadly parallel and complement previous findings regrading criticism and cognition assessed in a reaction-time assessment of negative information processing (Masland et al., 2015).
Racial Differences in Attributions, Perceived Criticism, and Upset: A Study With Black and White Community Participants
2018, Behavior TherapyCitation Excerpt :For example, Steketee et al. (2007) found that upset mediated the relationship between perceived criticism and weekly ratings of anxious mood for patients in treatment for obsessive-compulsive disorder or panic disorder with agoraphobia. Miklowitz et al. (2005) demonstrated that upset due to criticism, not perceived criticism, predicted treatment outcome for patients with bipolar disorder. Given the link between upset and clinical outcome, delving into the factors that may predict individuals’ upset is a worthwhile pursuit.