Hostname: page-component-848d4c4894-m9kch Total loading time: 0 Render date: 2024-05-22T23:38:18.952Z Has data issue: false hasContentIssue false
  • English
  • Français

The role of family systems in severe and recurrent psychiatric disorders: A developmental psychopathology view

Published online by Cambridge University Press:  01 September 2004

DAVID J. MIKLOWITZ
DAVID J. MIKLOWITZ
Affiliation:
University of Colorado, Boulder
Get access Rights & Permissions [Opens in a new window]

Abstract

Family systems theory has been highly influential in the study of recurrent psychiatric disorders. This review examines two interrelated domains: research on expressed emotion (EE) attitudes among relatives (criticism, hostility, or emotionally overinvolvement) and relapses of schizophrenia or bipolar disorder, and randomized trials of family intervention in these populations. The literature is discussed in terms of contemporary systems theory and concepts from developmental psychopathology research. Several conclusions are drawn: (a) levels of EE are correlated with caregivers' attributions regarding the controllability of patients' behaviors; (b) EE attitudes are associated with bidirectional, mutually influential cycles of interaction between relatives and patients; and (c) family psychoeducational therapy, when combined with pharmacotherapy, is associated with lower rates of relapse in schizophrenia and bipolar illness. Underlying disturbances in family systems may emerge in response to illness symptoms in a family member, but also have recursive effects on the developmental course of the illness once manifest. The nature and stability of these recursive effects will depend on dynamic processes in the patient, the relative, and their relationship. Future research should elucidate mediating and moderating variables in the pathways from EE to patients' outcomes, and the conditions under which family treatments bring about favorable outcomes of psychiatric disorder.Preparation of this article was supported by Grant MH62555 from the National Institute of Mental Health and a Distinguished Investigator Award from the National Alliance for Research on Schizophrenia and Depression. The author thanks Martha Tompson for her conceptual input.

Type
Research Article
Information
Development and Psychopathology , Volume 16 , Issue 3 , September 2004 , pp. 667 - 688
Copyright
© 2004 Cambridge University Press

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

REFERENCES

Akiskal, H. S., & Akiskal, K. (1992). Cyclothymic, hyperthymic, and depressive temperaments as subaffective variants of mood disorders. In A. Tasman & M. B. Riba (Eds.), American psychiatric press review of psychiatry (pp. 43–62). Washington, DC: American Psychiatric Press.
Altorfer, A., Kasermann, M. L., & Hirsbrunner, H. (1998). Arousal and communication, 1. The relationship between nonverbal, behavioral, and psychophysiological indices of the stress response. Journal of Psychophysiology 12, 40–59.Google Scholar
Bateson, G., Jackson, D. D., Haley, J., & Weakland, J. (1956). Toward a theory of schizophrenia. Behavioral Science 1, 251–264.CrossRefGoogle Scholar
Baucom, D. H., Epstein, N., & LaTaillade, J. J. (2002). Cognitive–behavioral couple therapy. In A. S. Gurman & N. S. Jacobson (Eds.), Clinical handbook of couple therapy (Vol. 3, pp. 26–58). New York: Guilford Press.
Baucom, D. H., Shoham, V., Mueser, K. T., Daiuto, A. D., & Stickle, T. R. (1998). Empirically supported couple and family interventions for marital distress and adult mental health problems. Journal of Consulting and Clinical Psychology 66, 53–88.CrossRefGoogle Scholar
Brewin, C. R. (1994). Changes in attribution and expressed emotion among the relatives of patients with schizophrenia. Psychological Medicine 24, 905–911.CrossRefGoogle Scholar
Brown, G. W., Birley, J. L. T., & Wing, J. K. (1972). Influence of family life on the course of schizophrenic disorder. British Journal of Psychiatry 121, 241–258.CrossRefGoogle Scholar
Butzlaff, R. L., & Hooley, J. M. (1998). Expressed emotion and psychiatric relapse: A meta-analysis. Archives of General Psychiatry 55, 547–552.CrossRefGoogle Scholar
Cicchetti, D., & Lynch, M. (1993). Toward an ecological/transactional model of community violence and child maltreatment: Consequences for children's development. Psychiatry 56, 96–118.CrossRefGoogle Scholar
Cicchetti, D., & Rogosch, F. A. (1997). The role of self-organization in the promotion of resilience in maltreated children. Development and Psychopathology 9, 797–815.Google Scholar
Cicchetti, D., & Rogosch, F. A. (2002). A developmental psychopathology perspective on adolescence. Journal of Consulting and Clinical Psychology 70, 6–20.CrossRefGoogle Scholar
Cicchetti, D., & Toth, S. L. (1992). The role of developmental theory in prevention and intervention. Development and Psychopathology 4, 489–494.CrossRefGoogle Scholar
Clarkin, J. F., Carpenter, D., Hull, J., Wilner, P., & Glick, I. (1998). Effects of psychoeducational intervention for married patients with bipolar disorder and their spouses. Psychiatric Services 49, 531–533.CrossRefGoogle Scholar
Colder, C. R., Lochman, J. E., & Wells, K. C. (1997). The moderating effects of children's fear and activity level on relations between parenting practices and childhood symptomatology. Journal of Abnormal Child Psychology 25, 251–263.CrossRefGoogle Scholar
Cornblatt, B., Obuchowski, M., Roberts, S., Pollack, S., & Erlenmeyer–Kimling, L. (1999). Cognitive and behavioral precursors of schizophrenia. Development and Psychopathology 11, 487–508.CrossRefGoogle Scholar
Coryell, W., Scheftner, W., Keller, M., Endicott, J., Maser, J., & Klerman, G. L. (1993). The enduring psychosocial consequences of mania and depression. American Journal of Psychiatry 150, 720–727.Google Scholar
Cox, M. J. & Paley, B. (1997). Families as systems. Annual Review of Psychology 48, 243–267.CrossRefGoogle Scholar
Craighead, W. E., & Miklowitz, D. J. (2000). Psychosocial interventions for bipolar disorder. Journal of Clinical Psychiatry, 61(Suppl. 13), 58–64.Google Scholar
Dimidjian, S., Martell, C. R., & Christensen, A. (2002). Integrative behavioral couple therapy. In A. S. Gurman & N. S. Jacobson (Eds.), Clinical handbook of couple therapy (3rd ed., pp. 251–277). New York: Guilford Press.
Dixon, L., McFarlane, W. R., Lefley, H., Lucksted, A., Cohen, M., Falloon, I., Mueser, K., Miklowitz, D., Solomon, P., & Sondheimer, D. (2001). Evidence-based practices for services to families of people with psychiatric disabilities. Psychiatric Services 52, 903–910.CrossRefGoogle Scholar
Doane, J. A., Goldstein, M. J., Miklowitz, D. J., & Falloon, I. R. H. (1986). The impact of individual and family treatment on the affective climate of families of schizophrenics. British Journal of Psychiatry 148, 279–287.CrossRefGoogle Scholar
Eisenberg, L. (1995). The social construction of the human brain. American Journal of Psychiatry 152, 1563–1575.CrossRefGoogle Scholar
Engel, G. L. (1977). The need for a new medical model: A challenge for biomedicine. Science 196, 129–136.CrossRefGoogle Scholar
Falloon, I. R. H., Boyd, J. L., McGill, C. W., Williamson, M., Razani, J., Moss, H. B., Gilderman, A. M., & Simpson, G. M. (1985). Family management in the prevention of morbidity of schizophrenia. Archives of General Psychiatry 42, 887–896.CrossRefGoogle Scholar
Fromm–Reichmann, F. (1948). Notes on the development of treatment of schizophrenics by psychoanalytic psychotherapy. Psychiatry 11, 263–273.CrossRefGoogle Scholar
Geller, B., & Luby, J. (1997). Child and adolescent bipolar disorder: A review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry 36, 1168–1176.CrossRefGoogle Scholar
Gilbert, R., Christensen, A., & Margolin, G. (1984). Patterns of alliance in distressed and multiproblem families. Family Process 23, 75–87.CrossRefGoogle Scholar
Gitlin, M. J., Swendsen, J., Heller, T. L., & Hammen, C. (1995). Relapse and impairment in bipolar disorder. American Journal of Psychiatry 152, 1635–1640.Google Scholar
Goldstein, M. J., & Miklowitz, D. J. (1995). The effectiveness of psychoeducational family therapy in the treatment of schizophrenic disorders. Journal of Marital and Family Therapy 21, 361–376.CrossRefGoogle Scholar
Goldstein, M. J., Talovic, S. A., Nuechterlein, K. H., Fogelson, D. L., Subotnik, K. L., & Asarnow, R. F. (1992). Family interaction versus individual psychopathology: Do they indicate the same processes in the families of schizophrenics? British Journal of Psychiatry, Suppl 18, 97–102.Google Scholar
Goldstein, T. R., Miklowitz, D. J., & Richards, J. A. (2002). The relationship between expressed emotion attitudes and individual psychopathology among relatives of bipolar patients. Family Process 41, 647–659.Google Scholar
Guttman, H. A. (1991). Systems theory, cybernetics, and epistemology. In A. S. Gurman & D. P. Kniskern (Eds.), Handbook of family therapy (Vol. II, pp. 41–62). New York: Brunner/Mazel.
Hatfield, A. B., Spaniol, L., & Zipple, A. M. (1987). Expressed emotion: A family perspective. Schizophrenia Bulletin 13, 221–226.CrossRefGoogle Scholar
Hinshaw, S. P., & Cicchetti, D. (2000). Stigma and mental disorder: Conceptions of illness, public attitudes, personal disclosure, and social policy. Development and Psychopathology 12, 555–598.CrossRefGoogle Scholar
Hogarty, G. E., Anderson, C. M., Reiss, D. J., Kornblith, S. J., Greenwald, D. P., Javna, C. D., & Madonia, M. J. (1986). Family psychoeductation, social skills training and maintenance chemotherapy in the aftercare treatment of schizophrenia: I. One-year effects of a controlled study on relapse and expressed emotion. Archives of General Psychiatry 43, 633–642.Google Scholar
Hogarty, G. E., Anderson, C. M., Reiss, D. J., Kornblith, S. J., Greenwald, D. P., Ulrich, R. F., & Carter, M. (1991). Family psychoeducation, social skills training, and maintenance chemotherapy in the aftercare of schizophrenia. Archives of General Psychiatry 48, 340–347.CrossRefGoogle Scholar
Hollon, S. D., Muñoz, R. F., Barlow, D. H., Beardslee, W. R., Bell, C. C., Bernal, G., Clarke, G. N., Franciosi, L. P., Kazdin, A. E., Kohn, L., Linehan, M. M., Markowitz, J. C., Miklowitz, D. J., Niederehe, G., Persons, J. B., & Sommers, D. (2002). Psychosocial intervention development for the prevention and treatment of depression: Promoting innovation and increasing access. Biological Psychiatry 52, 610–630.CrossRefGoogle Scholar
Hooley, J. M. (1998). Expressed emotion and locus of control. Journal of Nervous and Mental Disease 186, 374–378.CrossRefGoogle Scholar
Hooley, J. M., & Gotlib, I. H. (2000). A diathesis-stress conceptualization of expressed emotion and clinical outcome. Applied and Preventive Psychology 9, 131–151.Google Scholar
Hooley, J. M., & Hiller, J. B. (2000). Expressed emotion and personality. Journal of Abnormal Psychology 109, 40–44.CrossRefGoogle Scholar
Hooley, J. M., & Richters, J. (1995). Expressed emotion: A developmental perspective. In D. Cicchetti & S. L. Toth (Eds.), Emotion, cognitions, and representations. Rochester, NY: University of Rochester Press.
Hooley, J. M., Rosen, L. R., & Richters, J. E. (1995). Expressed emotion: Toward clarification of a critical construct. In G. Miller (Ed.), The behavioral high-risk paradigm in psychopathology (pp. 88–120). New York: Springer–Verlag.
Hooley, J. M., & Yurgelun–Todd, D. (2001). The neural correlates of maternal criticism in recovered depressed and control subjects. Paper presented at the 16th Annual Meeting of the Society for Research in Psychopathology, Madison, WI.
Jamison, K. R. (2000). Suicide and bipolar disorder. Journal of Clinical Psychiatry, 61(Suppl. 9), 47–56.Google Scholar
Kandel, E. R. (1998). A new intellectual framework for psychiatry. American Journal of Psychiatry 155, 457–469.CrossRefGoogle Scholar
Kaplan, K. J., & Harrow, M. (1999). Psychosis and functioning as risk factors for later suicidal activity among schizophrenia and schizoaffective patients: A disease-based interactive model. Suicide and Life Threatening Behavior 29, 10–24.Google Scholar
Kazdin, A. E. (2000). Developing a research agenda for child and adolescent psychotherapy. Archives of General Psychiatry 57, 829–835.CrossRefGoogle Scholar
Kleinman, A. (1988). The illness narratives: Suffering, healing, and the human condition. New York: Basic Books.
Kottgen, C., Sonnichsen, I., Mollenhauer, K., & Jurth, R. (1984). Group therapy with the families of schizophrenic patients: Results of the Hamburg Camberwell-Family Interview Study, III. International Journal of Family Psychiatry 5, 84–94.Google Scholar
Leff, J., Berkowitz, R., Shavit, N., Strachan, A., Glass, I., & Vaughn, C. (1990). A trial of family therapy versus a relatives' group for schizophrenia: Two-year follow-up. British Journal of Psychiatry 157, 571–577.CrossRefGoogle Scholar
Leff, J., Kuipers, L., Berkowitz, R., & Sturgeon, D. (1985). A controlled trial of social intervention in the families of schizophrenic patients: Two-year follow-up. British Journal of Psychiatry 146, 594–600.CrossRefGoogle Scholar
Lewinsohn, P. M., Klein, D. N., & Seeley, J. R. (1995). Bipolar disorders in a community sample of older adolescents: Prevalence, phenomenology, comorbidity, and course. Journal of the American Academy of Child and Adolescent Psychiatry 34, 454–463.CrossRefGoogle Scholar
Linszen, D., Dingemanns, P., Van der Does, J. W., Nugter, A., Scholte, P., Lenior, R., & Goldstein, M. J. (1996). Treatment, expressed emotion and relapse in recent onset schizophrenic disorders. Psychological Medicine 26, 333–342.CrossRefGoogle Scholar
Masten, A. S., & Coatsworth, J. D. (1998). The development of competence in favorable and unfavorable environments: Lessons from research on successful children. American Psychologist 53, 205–220.CrossRefGoogle Scholar
McFarlane, W. R., Link, B., Dushay, R., Marchal, J., & Crilly, J. (1995). Psychoeducational multiple family groups: Four-year relapse outcome in schizophrenia. Family Process 34, 127–144.CrossRefGoogle Scholar
McFarlane, W. R., Lukens, E., Link, B., Dushay, R., Deakins, S. A., Newmark, M., Dunne, E. J., Horen, B., & Toran, J. (1995). Multiple-family groups and psychoeducation in the treatment of schizophrenia. Archives of General Psychiatry 52, 679–687.CrossRefGoogle Scholar
Miklowitz, D. J., George, E. L., Axelson, D. A., Kim, E. Y., Birmaher, B., Schneck, C., Beresford, C., Craighead, W. E., & Brent, D. A. (in press). Family-focused treatment for adolescents with bipolar disorder. Journal of Affective Disorders.
Miklowitz, D. J., George, E. L., Richards, J. A., Simoneau, T. L., & Suddath, R. L. (2003). A randomized study of family-focused psychoeducation and pharmacotherapy in the outpatient management of bipolar disorder. Archives of General Psychiatry 60, 904–912.CrossRefGoogle Scholar
Miklowitz, D. J., & Goldstein, M. J. (1997). Bipolar disorder: A family-focused treatment approach. New York: Guilford Press.
Miklowitz, D. J., Goldstein, M. J., Doane, J. A., Nuechterlein, K. H., Strachan, A. M., Snyder, K. S., & Magana, A. (1989). Is expressed emotion an index of a transactional process? I. Parents' affective style. Family Process 28, 153–167.Google Scholar
Miklowitz, D. J., Goldstein, M. J., & Falloon, I. R. H. (1983). Premorbid and symptomatic characteristics of schizophrenics from families with high and low levels of expressed emotion. Journal of Abnormal Psychology 92, 359–367.CrossRefGoogle Scholar
Miklowitz, D. J., Goldstein, M. J., Falloon, I. R. H., & Doane, J. A. (1984). Interactional correlates of expressed emotion in the families of schizophrenics. British Journal of Psychiatry 144, 482–487.CrossRefGoogle Scholar
Miklowitz, D. J., Goldstein, M. J., & Nuechterlein, K. H. (1995). Verbal interactions in the families of schizophrenic and bipolar affective patients. Journal of Abnormal Psychology 104, 268–276.CrossRefGoogle Scholar
Miklowitz, D. J., Goldstein, M. J., Nuechterlein, K. H., Snyder, K. S., & Mintz, J. (1988). Family factors and the course of bipolar affective disorder. Archives of General Psychiatry 45, 225–231.CrossRefGoogle Scholar
Miklowitz, D. J., & Tompson, M. C. (2003). Family variables and interventions in schizophrenia. In G. P. Sholevar & L. D. Schwoeri (Eds.), Textbook of marital and family therapy (pp. 585–617). Washington, DC: American Psychiatric Publishing, Inc.
Minuchin, P. (1985). Families and individual development: Provocations from the field of family therapy. Child Development 56, 289–302.CrossRefGoogle Scholar
Murray, C. J. L., & Lopez, A. D. (1996). The global burden of disease: A comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Boston: Harvard University Press.
Nuechterlein, K. H., Snyder, K. S., & Mintz, J. (1992). Paths to relapse: Possible transactional processes connecting patient illness onset, expressed emotion, and psychotic relapse. British Journal of Psychiatry 161, 88–96.Google Scholar
Pitschel–Walz, G., Leucht, S., Bäuml, J., Kissling, W., & Engel, R. R. (2001). The effect of family interventions on relapse and rehospitalization in schizophrenia: A meta-analysis. Schizophrenia Bulletin 27, 73–92.CrossRefGoogle Scholar
Racenstein, J. M., Harrow, M., Reed, R., Martin, E., Herbener, E., & Penn, D. L. (2002). The relationship between positive symptoms and instrumental work functioning in schizophrenia: A 10 year follow-up study. Schizophrenia Research 56, 95–103.CrossRefGoogle Scholar
Rea, M. M., Tompson, M., Miklowitz, D. J., Goldstein, M. J., Hwang, S., & Mintz, J. (2003). Family focused treatment vs. individual treatment for bipolar disorder: Results of a randomized clinical trial. Journal of Consulting and Clinical Psychology 71, 482–492.Google Scholar
Rosenfarb, I. S., Goldstein, M. J., Mintz, J., & Nuechterlein, K. H. (1995). Expressed emotion and subclinical psychopathology observable within the transactions between schizophrenic patients and their family members. Journal of Abnormal Psychology 104, 259–267.CrossRefGoogle Scholar
Sachs, G. S., Thase, M. E., Otto, M. W., Bauer, M., Miklowitz, D., Wisniewski, S. R., Lavori, P., Lebowitz, B., Rudorfer, M., Frank, E., Nierenberg, A. A., Fava, M., Bowden, C., Ketter, T., Marangell, L., Calabrese, J., Kupfer, D., & Rosenbaum, J. F., et al. (2003). Rationale, design, and methods of the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). Biological Psychiatry 53, 1028–1042.CrossRefGoogle Scholar
Schooler, N. R., Keith, S. J., Severe, J. B., Matthews, S. M., Bellack, A. S., Glick, I.D., Hargreaves, W. A., Kane, J. M., Ninan, P. T., Frances, A., Jacobs, M., Lieberman, J. A., Mance, R., Simpson, G. M., & Woerner, M. G. (1997). Relapse and rehospitalization during maintenance treatment of schizophrenia: The effects of dose reduction and family treatment. Archives of General Psychiatry 54, 453–463.CrossRefGoogle Scholar
Selvini, M. P., Boscolo, L., Cecchin, G., & Prata, G. (1980). Hypothesizing–circularity–neutrality: Three guidelines for the conductor of the session. Family Process 19, 3–12.CrossRefGoogle Scholar
Simoneau, T. L., Miklowitz, D. J., Richards, J. A., Saleem, R., & George, E. L. (1999). Bipolar disorder and family communication: Effects of a psychoeducational treatment program. Journal of Abnormal Psychology 108, 588–597.CrossRefGoogle Scholar
Simoneau, T. L., Miklowitz, D. J., & Saleem, R. (1998). Expressed emotion and interactional patterns in the families of bipolar patients. Journal of Abnormal Psychology 107, 497–507.CrossRefGoogle Scholar
Strachan, A. M., Feingold, D., Goldstein, M. J., Miklowitz, D. J., & Nuechterlein, K. H. (1989). Is expressed emotion an index of a transactional process? II. Patient's coping style. Family Process 28, 169–181.Google Scholar
Strachan, A. M., Leff, J. P., Goldstein, M. J., Doane, J. A., & Burtt, C. (1986). Emotional attitudes and direct communication in the families of schizophrenics: A cross-national replication. British Journal of Psychiatry 149, 279–287.CrossRefGoogle Scholar
Sturgeon, D., Turpin, G., Kuipers, L., Berkowitz, R., & Leff, J. (1984). Psychophysiological responses of schizophrenic patients to high and low expressed emotion relatives: A follow-up study. British Journal of Psychiatry 145, 62–69.CrossRefGoogle Scholar
Tarrier, N., Barrowclough, C., Porceddu, K., & Fitzpatrick, E. (1994). The Salford Family Intervention project: Relapse rates of schizophrenia at five and eight years. British Journal of Psychiatry 165, 829–832.CrossRefGoogle Scholar
Tarrier, N., Barrowclough, C., Porceddu, K., & Watts, S. (1988). The assessment of psychophysiological reactivity to the expressed emotion of the relatives of schizophrenic patients. British Journal of Psychiatry 152, 618–624.CrossRefGoogle Scholar
Tarrier, N., Barrowclough, C., Vaughn, C., Bamrah, J. S., Porceddu, K., Watts, S., & Freeman, H. (1988). The community management of schizophrenia: A controlled trial of a behavioral intervention with families to reduce relapse. British Journal of Psychiatry 153, 532–542.CrossRefGoogle Scholar
Tarrier, N., Vaughn, C., Lader, M. H., & Leff, J. P. (1979). Bodily reactions to people and events in schizophrenics. Archives of General Psychiatry 36, 311–315.CrossRefGoogle Scholar
Telles, C., Karno, M., Mintz, J., Paz, G., Arias, M., Tucker, D., & Lopez, S. (1995). Immigrant families coping with schizophrenia: Behavioral family intervention versus case management with a low-income Spanish-speaking population. British Journal of Psychiatry 167, 473–479.CrossRefGoogle Scholar
Tompson, M. C., Goldstein, M. J., & Rea, M. M. (1996). Psychoeducational family intervention: Individual differences in response to treatment. In J. M. Kane & R. J. van den Bosch (Eds.), Compliance and relapse in practice (pp. 21–28). Denmark: Lundbeck.
Vaughn, C. E., & Leff, J. P. (1976). The influence of family and social factors on the course of psychiatric illness: A comparison of schizophrenia and depressed neurotic patients. British Journal of Psychiatry 129, 125–137.CrossRefGoogle Scholar
Vaughan, K., Doyle, M., McConaghy, N., Blaszczynski, A., Fox, A., & Tarrier, N. (1992). The Sydney Intervention Trial: A controlled trial of relatives' counseling to reduce schizophrenic relapse. Social Psychiatry and Psychiatric Epidemiology 27, 16–21.CrossRefGoogle Scholar
Weisman, A. G., Gomes, L. G., & Lopez, S. R. (2003). Shifting blame away from ill relatives: Latino families' reactions to schizophrenia. Journal of Nervous and Mental Disease 191, 1–8.CrossRefGoogle Scholar
Weisman, A. G., Nuechterlein, K. H., Goldstein, M. J., & Snyder, K. S. (1998). Expressed emotion, attributions, and schizophrenic symptom dimensions. Journal of Abnormal Psychology 107, 355–359.CrossRefGoogle Scholar
Wendel, J. S., Miklowitz, D. J., Richards, J. A., & George, E. L. (2000). Expressed emotion and attributions in the relatives of bipolar patients: An analysis of problem-solving interactions. Journal of Abnormal Psychology 109, 792–796.CrossRefGoogle Scholar
Woo, S. M., Goldstein, M. J., & Nuechterlein, K. H. (1997). Relatives' expressed emotion and non-verbal signs of subclinical psychopathology in schizophrenic patients. British Journal of Psychiatry 170, 58–61.CrossRefGoogle Scholar
Wyatt, R. J., & Henter, I. (1995). An economic evaluation of manic-depressive illness. Social Psychiatry and Psychiatric Epidemiology 30, 213–219.Google Scholar
Wyatt, R. J., Henter, I., Leary, M. C., & Taylor, E. (1995). An economic evaluation of schizophrenia, 1991. Social Psychiatry and Psychiatric Epidemiology 30, 196–205.Google Scholar
Wynne, L. C., Shields, C. G., & Sirkin, M. I. (1992). Illness, family theory, and family therapy: I. Conceptual issues. Family Process 31, 3–18.Google Scholar