04 - 4. Family life in relation to major mental il

4. Family life in relation to major mental illnesses

© SPMM Course 4. Family life in relation to major mental illnesses Family is essentially the most basic social unit and microcosm of an individual. The General Systems Model of families holds that families are systems where every action in a family produces a reaction in one or more of its members. Such a system has external boundaries and internal rules, and every member is supposed to play a relatively stable but interchangeable role. Family cycle:  Stage 1: formation of the new family: 2 individuals unite - the  first child is born. Tasks include formation of working dyad and restructuring relationships with families of origin.  Stage 2: child rearing stage: birth of child  adolescence  Maintaining satisfactory marital relationship amidst the demands of childrearing is a major task.  Stage 3: child launching: Children leave home. Tasks include re-establishing individual interests and reexamining the marital relationship.  Stage 4: return of independence – growth and extension of family leads to the task of maintaining ties across generations  Stage 5: dissolution of the family: occurs due to decline or demise of partners. Family instability can affect children to a various extent depending on sex (boys affected > girls), age (younger affected > older children), and temperament hyperactive affected > placid). This has a demonstrable effect on a child’s cognitive achievements; the most common psychopathology noted is a behavioural difficulty. Family systems have been studied in detail with respect to schizophrenia especially. Lidz studied family systems in relation to schizophrenia and described two ‘schizophrenogenic’ family patterns:  Marital schism: family is in a state of disequilibrium due to repeated threats of parental separation. Parents downgrade roles of each other and may even attempt to collude with children and exclude partners.  Marital skew: family is at an equilibrium that is skewed and achieved at an expense of the distorted parental relationship. One parent may be dominant and other submissive, making the marriage ‘a stable fit’. Wynne and colleagues described certain communication patterns that may relate to the later development of perceptual and thought disorders in schizophrenia. Pseudo-hostility and pseudo-mutuality refer to the disjointed or fragmented communication where the child is

© SPMM Course forced to accept and develop a pattern of communication that will negate and deny the existence of meaningless relationships in the family. Bateson described the double-bind relationship where superficial verbal communications contradict the behavioural and deeper communications among the members of a family. These mixed messages keep a growing child in a double bind (cannot be correct either way) that can later increase the risk of psychosis. Freida Fromm-Reichmann coined the concept of schizophrenogenic-mother. These mothers were described as 'rejecting, impervious to the feelings of others, rigid in moralism concerning sex and had a significant fear of intimacy'. Causal links between the above four family functions and schizophrenia are disputed, and these models have fallen out of favour in recent times. There is no experimental evidence to support these claims and any small data regarding the above theories are poorly reproducible. Expressed emotions concept was developed by Brown & Rutter in 1966 as a part of the Camberwell Family Interview [CFI] and later modified by Vaughn & Leff in 1976. The ratings were based on content and prosodic aspects and emphasis of speech. Five measures are considered;

1. Critical comments
2. Positive remarks
3. Emotional over involvement
4. Hostility
5. Emotional warmth The final scores of emotional over-involvement, critical comments and hostility were the most predictive measures for relapse of schizophrenia. CFI is a long interview process where individual members of a family are interviewed (including the patient). If one relative is classified as high EE person, then the whole family could be classified as a high EE family. CFI ratings based on interviewing parents singly have the most predictive value. A Five Minute Speech sample (FMSS) measure was introduced as a substitute for CFI, but it tends to underestimate EE. FMSS is more useful for measuring professional or staff carers’ level of EE. Studies have indicated:  Worldwide the proportion of high EE in carers of patients with schizophrenia is 52%. Lowest rates are found in India and other developing nations.  The strength of association between relapse and EE is identical for both genders.

© SPMM Course  A meta-analysis of EE data reveals that for patients living in situations rated as showing high expressed emotion, the relapse rate is 50%, whereas in the ‘low expressed emotion group’ the rate is 21%.  In a majority of the studies, high expressed emotion was predictive of relapse in symptoms of schizophrenia 9 months later for both genders. A significant amount of face-to-face contact (more than 35 hours per week) with a relative with a high expressed emotion score increased the risk of relapse, but in households with a low expressed emotion score, high levels of contact appeared to be protective.  Pakistani families in the UK were more likely to be rated as high expressed emotion than White families, indicating that components such as emotional over-involvement may be cultural rather than pathogenic traits (Hashemi & Cochrane, 1999).