French version of the Family Attitude Scale: Psychometric properties and relation of attitudes to the respondent's psychiatric status
Introduction
“Expressed emotion” (EE) refers to communication of criticism, hostility or rejection about someone with a psychiatric illness, or reports of emotional over-involvement with them. It originated in the 1950s, following observation of interactions between inpatients with schizophrenia and their families (Brown et al., 1958, Brown et al., 1962). This theory is conceptually akin to other contemporaneous theories on family communication (Bateson et al., 1956, Bateson and Ruesch, 1951), but unlike those theories, EE is focused on family factors that increase risks of relapse in psychiatric disorders, rather than advancing a general theory of human communication (Favez, 2010). Research on EE has shown that risks of relapse in schizophrenia are substantially higher in families with high EE, especially when there is a substantial amount of contact between the patient and their family (Brown et al., 1958, Brown et al., 1962, Butzlaff and Hooley, 1998, Kavanagh, 1992). EE was argued to act as a major stressor, which triggers intense physiological activation, which in turn increases the risk of psychotic symptoms, social withdrawal and ultimately, relapse (Brown et al., 1972, Rosenfarb et al., 1995, Rosenfarb et al., 2006). Links between EE and relapse are also seen in patients with mood (Hooley et al., 1986, Hooley and Teasdale, 1989), anxiety (Chambless et al., 2001) and alcohol use disorders (O'Farrell et al., 1998).
Several instruments have been developed to measure the presence of EE in the familial environment. The “Camberwell Family Interview” (CFI; Brown et al., 1972), updated and shortened by Vaughn and Leff (1976), is the gold standard instrument, but necessitates initial training for interviewers and several hours for each individual interview and its subsequent rating. A shorter alternative is the “Five Minute Speech Sample” (FMSS; Gottschalk and Gleser, 1969, Magana et al., 1986) during which a family member speaks about his or her perception of the patient and their relationship for 5 min without interruption. Responses are coded using the CFI scoring procedures. However, the FMSS still requires training, and it misses some instances of high EE that are seen in a full CFI. As a result, its predictive validity for relapse is less well established than for the CFI (Hooley and Parker, 2006).
An alternative is to use a self-report instrument, which can be delivered without incurring the costs of training and of the administration and scoring of interviews. The Family Attitude Scale (FAS; Kavanagh et al., 1997) is one such instrument with strong psychometric characteristics. In an initial study, the FAS was administered to undergraduate students and their parents, and to relatives of people with schizophrenia spectrum disorders (Kavanagh et al., 1997). Strong evidence for a single-factor solution was obtained, and the internal consistency of the scale was high for parental FAS scores in both student and clinical samples (Cronbach alpha≥0.95). In the student sample, parental FAS scores significantly correlated with State and Trait Anger and Anxiety on the State-Trait Personality Inventory (Spielberger et al., 1983) (Median r across the four scales=0.28, p<0.001 for mothers, 0.44, p<0.001 for fathers) and with anger expression (r=0.35, p<0.001 for mothers, 0.49, p<0.001 for fathers) on the Anger Expression Inventory (Spielberger et al., 1985). In parents of people with schizophrenia spectrum disorders, parental Hostility and Criticism on the CFI were significantly associated with more negative parental FAS scores, especially in the case of maternal Criticism on the CFI and maternal FAS (r=0.66, p<0.001). Subsequent studies have confirmed the validity of both the English (Kavanagh et al., 2008) and Japanese versions of the FAS (Fujita et al., 2002) against the CFI. The FAS has also shown predictive validity for illness relapse in two samples of patients with psychosis (Kavanagh et al., 2008), although the relationship was weaker than when the CFI was used.
Up to now, information on the FAS scores of family members of patients with psychiatric disorders other than psychoses is sparse. Moreover, measures of EE have seldom been used to document attitudes and behaviors in relation to a marital partner. Nor are there many studies on potential effects of a respondent's own symptoms or diagnoses on EE or FAS scores. In parallel to a patient's symptoms influencing family members' adjustment to a given disorder (Albert et al., 2010), EE or attitudes towards another family member may well be affected by the respondent's own symptoms (Barrowclough and Parle, 1997). One study on 17 couples with depressed partners (Florin et al., 1992) showed that high EE of both the respondent and their depressed partner were significantly more common when the partner had a higher score on the Beck Depression Inventory (Beck et al., 1961). The study using the Japanese version of the FAS found the FAS ratings of 57 family members of 41 schizophrenic patients to be higher when they had more physical complaints themselves (Fujita et al., 2002). However, the FAS ratings of the family members were not significantly higher when they were more anxious or depressed, or had more social dysfunction (Fujita et al., 2002). A recent Polish study (Pankiewicz et al., 2012) showed no differences between mean FAS scores in 85 couples, where one or both partners suffered from Panic or Generalized Anxiety Disorders, than where neither had these disorders. Further research on this issue is needed. Moreover, studies on associations between EE and subthreshold mood disorders, which have gained increasing interest in contemporary psychiatry, are entirely lacking.
Given these gaps in existing literature regarding the sensitivity of the FAS to EE in non-psychotic disorders, the aims of the present study were to use a large general population sample: (a) to provide a short, internally coherent measure of EE in French-speaking cultures, by creating a French translation of the FAS, and testing its internal structure; (b) to establish the criterion validity of the translated FAS with other measures of relationship functioning (in particular, the Dyadic Adjustment Scale of Spanier (1976)); (c) to provide further data on the validity of the FAS, by examining relationships between FAS scores, and the respondent's own anxiety symptoms and anxiety, affective, psychotic and substance use disorders; and (d) to examine the extent of reciprocity between the FAS of respondents and their partners. An examination of associations between the respondent's own symptoms or diagnoses and the level of EE would extend the initial concepts, which primarily focused on the partner's psychopathology, to the role of the respondent's psychopathology in the development of emotional communication within the family system.
Section snippets
Participants
The present sample was derived from the CoLaus study, which included information on 6738 adults aged 35–75 years who were randomly selected from a list of residents of Lausanne, Switzerland, in 2003. That project assessed cardiovascular risk factors and collected DNA and plasma samples for the study of genetic variants and biomarkers (Firmann et al., 2008). The PsyCoLaus study (Preisig et al., 2009), which was based on a subsample of CoLaus, constituted its psychiatric arm. It included a
Sample characteristics
A total of 2072 (55.7%) of PsyColaus participants (49.9% female, mean age: 51.3 years, S.D.: 8.7 years) had completed the FAS after exclusion of questionnaires with more than 10% of missing data. In this subsample, 70.6% were married, 75% were of Swiss origin and 25.6% held professional specialty positions. Participants who completed all items of the FAS differed from those who did not in their gender (respectively, 50% vs. 57% female; χ2=18.0, d.f.=1, p<0.0001), age (51.3 vs. 50.5 years; F=
Discussion
Our first goal was to test the internal structure of the French FAS. Results showed satisfactory internal consistency, and the confirmatory factor analysis revealed an excellent fit of the single-factor solution. Our second goal was to establish the criterion validity of the French FAS. A lower FAS score, reflecting more positive attitudes and behaviors towards the partner, was strongly associated with a higher score on the Dyadic Adjustment Scale (predicting 69% of the variance). While more
Acknowledgments
This research was supported by three grants from the Swiss National Science Foundation (Grants nos. #32003b-105993, #32003b-118308 and #33csc0-122661) and two grants from GlaxoSmithKline clinical genetics to G. Waeber and M. Preisig.
The authors would like to express their gratitude to the Lausanne inhabitants who volunteered to participate in the PsyCoLaus study. We would also like to thank all the investigators of the CoLaus study, who made the psychiatric study possible, as well as many GSK
References (62)
- et al.
Family accommodation in obsessive–compulsive disorder: Relation to symptom dimensions, clinical and family characteristics
Psychiatry Research
(2010) - et al.
Toward a re-definition of subthreshold bipolarity: epidemiology and proposed criteria for bipolar-II, minor bipolar disorders and hypomania
Journal of Affective Disorders
(2003) - et al.
Diagnostic interview for genetic studies DIGS: inter-rater and test–retest reliability of alcohol and drug diagnoses
Drug and Alcohol Dependence
(2002) - et al.
Post-hospital adjustment of chronic mental patients
Lancet
(1958) - et al.
Family attitude scale: measurement of criticism in the relatives of patients with schizophrenia in Japan
Psychiatry Research
(2002) - et al.
The family attitude scale: reliability and validity of a new scale for measuring the emotional climate of families
Psychiatry Research
(1997) - et al.
Predictive validity of the Family Attitude Scale in people with psychosis
Psychiatry Research
(2008) - et al.
A brief method for assessing expressed emotion in relatives of psychiatric-patients
Psychiatry Research
(1986) - et al.
Validation of the French version of the Parental Bonding Instrument in adults
Personality and Individual Differences
(1999) - et al.
Anxiety disorders in intimate partners and the quality of their relationship
Journal of Affective Disorders
(2012)
The depressive spectrum: diagnostic classification and course
Journal of Affective Disorders
Traduction francaise de l'Echelle d'Adjustment Dyadique (French translation of the Dyadic Adjustment Scale)
Canadian Journal of Behavioral Science
Appraisal, psychological adjustment and expressed emotion in relatives of patients suffering from schizophrenia
British Journal of Psychiatry
Toward a theory of schizophrenia
Behavioral Science
Communication. The Social Matrix of Psychiatry
An inventory for measuring depression
Archives of General Psychiatry
The influence of family life on the course of schizophrenic illness
British Journal of Preventive Social Medicine
Influence of family life on course of schizophrenic disorders: replication
British Journal of Psychiatry
Expressed emotion and psychiatric relapse: a meta-analysis
Archives of General Psychiatry
Predicting expressed emotion: a study with families of obsessive–compulsive and agoraphobic outpatients
Journal of Family Psychology
Utility of confirmatory factor analysis in test validation research
Journal of Consulting and Clinical Psychology
Assessing marital quality with distressed and nondistressed couples: a comparison and equivalency table for three frequently used measures
Journal of Marriage and the Family
Coefficient alpha and the internal structure of tests
Psychometrika
Manual of the Eysenck Personality Questionnaire
La structure de la personnalité chez les français confrontée à celle des anglais, comparaison “cross-culturelle” (The personality structure of the French compared to the English people, “cross-cultural” comparison)
Personnalité
L'examen Clinique de la Famille. Modèles et Instruments d'Évaluation (Clinical Examination of the Family. Assessment Models and Instruments)
Expressed emotion in depressed patients and their partners
Family Process
The CoLaus study: a population-based study to investigate the epidemiology and genetic determinants of cardiovascular risk factors and metabolic syndrome
BMC Cardiovascular Disorders
A User's Guide to the General Health Questionnaire
The Measurement of Psychological States Through Analysis of Verbal Behavior
Individual psychopathology and marital distress. Analyzing the association and implications for therapy
Behavior Modification
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