Expressed emotion and the course of schizophrenia in Pakistan

  • Sarosh SadiqEmail author
  • Kausar Suhail
  • John Gleeson
  • Mario Alvarez-Jimenez
Original Paper



Aim of the study is to evaluate the predictive power of Expressed Emotion in Schizophrenia relapse in Pakistan.


A longitudinal study was conducted comprising 53 in-patients’ sample diagnosed with Schizophrenia and their 101 key carers. Participants fulfilled DSM-IV-TR criteria for Schizophrenia based on Structural Clinical Interview for the DSM-IV diagnosis. Symptomatic status was measured through Brief Psychiatric Rating Scales-Expanded (BPRS-E). Caregivers’ level of EE was assessed through Camberwell Family Interview (CFI). Patients were followed up for 9 months after hospital discharge.


Relapse rate for patients with high-EE household was 72% as compared with 36% in the low-EE household. Logistic Regression showed a positive relationship between high-EE and relapse (CI 0.06–0.80; p < 0.05). Both hostility and critical comments emerged as significant predictors of relapse. The odds ratio showed that a one unit increase in caregivers’ score on the CCs and hostility scales were associated with a 1.29 (CI 1.06–1.56; p < 0.05) and 1.89 (CI 1.14–3.13; p < 0.05) times increased rate of relapse, respectively. Conversely, a non-significant relationship was observed between EOI and relapse.


The findings from this study confirmed the validity of EE construct in predicting schizophrenia relapse in a Pakistani sample. However, medication compliance has not been experimentally controlled and that is one of the limitations of the study.


Expressed emotion Follow-up Relapse Schizophrenia 


  1. 1.
    Alvarez-Jimenez M, Priede A, Hetrick SE, Bendall S, Killackey E, Parker AG, McGorry PD, Gleeson JF (2012) Risk factors for relapse following treatment for first episode psychosis: a systematic review and meta-analysis of longitudinal studies. Schizophr Res 139:116–128CrossRefPubMedGoogle Scholar
  2. 2.
    Jenkins JH, Karno M (1992) The meaning of expressed emotion: theoretical issues raised by cross-cultural research. Am J Psychiatr 149:9–21CrossRefPubMedGoogle Scholar
  3. 3.
    Bhugra D, McKenzie K (2003) Expressed emotion across cultures. Adv Psychiatr Treatm 9:342–348CrossRefGoogle Scholar
  4. 4.
    Brown GW, Birley JLT, Wing JK (1972) Influence of family life on the course of schizophrenic disorders: a replication. Br J Psychiat 21:241–258CrossRefGoogle Scholar
  5. 5.
    Hooley JM (2006) Expressed emotion and relapse of psychopathology. Annu Rev Clin Psychol 3:329–352. doi: 10.1146/annurev.clinpsy.2.022305.095236 CrossRefGoogle Scholar
  6. 6.
    Karno M, Jenkins JH, Selva ADL, Santana F, Telles C, Lopea S, Mintz J (1987) Expressed emotions and schizophrenia outcome among Mexican-American families. J Nerv Ment Dis 175(3):143–151CrossRefPubMedGoogle Scholar
  7. 7.
    Brown GW, Rutter M (1966) The measurement of family activities and relationships: a methodological study. Hum Relat 19:241–263CrossRefGoogle Scholar
  8. 8.
    Vaughn CE, Leff JP (1976) The influence of family and social factors on the course of psychiatric illness. Br J Psychiatr 129:125–137CrossRefGoogle Scholar
  9. 9.
    Banerjee AG, Retamero C (2014) Expressed emotion—a determinant of relapse in schizophrenia: a case report and literature review. J Psychiatr Brain Funct 1(4)Google Scholar
  10. 10.
    Butzlaff RL, Hooley JM (1998) Expressed emotions and psychiatric relapse: a meta-analysis. Arch Gen Psychiatry 55(6):547–552CrossRefPubMedGoogle Scholar
  11. 11.
    Leff J, Wig NN, Ghosh A, Bedi H, Menon DK, Kuipers L, Korten A, Ernberg G, Day R, Sartorius N, Jablensky A (1987) III. Influence of relatives’ expressed emotion on the course of schizophrenia in Chandigarh. Br J Psychiatry 151:166–173CrossRefPubMedGoogle Scholar
  12. 12.
    Hashemi AH, Cochrane R (1999) Expressed emotion and schizophrenia: a review of studies across cultures. Int Rev Psychiatry 11:219–224CrossRefGoogle Scholar
  13. 13.
    Moline RA, Singh S, Morris A, Meltzer HY (1985) Family expressed emotion and relapse in schizophrenia in 24 urban American patients. Am J Psychiatry 142(9):1078–1081CrossRefPubMedGoogle Scholar
  14. 14.
    Singh S, Harley K, Suhail K (2013) Cultural specificity of emotional over involvement: a systematic review. Schizophr Bull 39:449–463CrossRefPubMedGoogle Scholar
  15. 15.
    Nuechterlien KH, Synder KS, Dawson ME, Rappe S, Gitlin M, Fogelson MD (1986) Expressed emotion, fixed dose fluphenazine decanoate maintenance, and relapse in recent onset schizophrenia. Psychopharmacol Bull 22:633–639Google Scholar
  16. 16.
    Azhar MZ, Varma SL (1996) Relationship of expressed emotion with relapse of schizophrenia patients in Kelantan. Singapore Med J 37:82–85PubMedGoogle Scholar
  17. 17.
    Wig NN, Menon DK, Bedi H, Ghoshi A, Kuippers L, Leff J, Korten A, Day R, Sartorious N, Ernberg G, Jablensky A (1987) The distribution of EE components among relatives of schizophrenic patients in Aarhus and Chandigarh. Br J Psychiatry 151:160–165CrossRefPubMedGoogle Scholar
  18. 18.
    Ikram A, Suhail K, Jaferi SZ, Singh S (2011) Rates of expressed emotion in Pakistani relatives of patients with schizophrenia. Isr J Psychiatr Relat Sci 48(2):74–81Google Scholar
  19. 19.
    Kamal A (1995) Variable in expressed emotion associated with relapse: a comparison between depressed and schizophrenic samples in an Egyptian community. Curr Psychiatry 2(2):211–216Google Scholar
  20. 20.
    Mino Y, Inoue S, Tanaka S, Tsuda T (1997) Expressed emotion among families and course of schizophrenia in Japan: a 2-year cohort study. Schizophr Res 24:333–339CrossRefPubMedGoogle Scholar
  21. 21.
    Philips MR, Xiong W (1995) Expressed emotion in mainland China: Chinese families with schizophrenic patients. Int J Ment Health 24(3):54–57CrossRefGoogle Scholar
  22. 22.
    Monking HS, Buchkremer G (1995) Emotional family atmosphere and relapse: investigations on the role of relapse definition, duration of illness and resignation of relatives. Eur Psychiatr 10(2):85–91. doi: 10.1016/0924-9338(96)80318-X CrossRefGoogle Scholar
  23. 23.
    Nomura H, Inoue S, Kamimura N, Shimodera S, Mino Y, Gregg L, Tarrier N (2005) A cross-cultural study on expressed emotion in carers of people with dementia and schizophrenia: Japan and England. Soc Psychiatry Psychiatr Epidemiol 40:564–570. doi: 10.1007/s00127-005-0924-z CrossRefPubMedGoogle Scholar
  24. 24.
    Roseliza-Murni A, Oei TPS, Fatimah Y, Asmawati D (2013) Schizophrenia relapse in Kuala Lumpur, Malaysia: DO relatives’ expressed emotion and personality traits matter? Compr Psychiatr 55(1):188–198.
  25. 25.
    Vaughn CE, Karen SS, Jones S, Freeman WB, Falloon IRH (1984) Family factors in schizophrenic relapse replication in California of British research on expressed emotion. Arch Gen Psychiatry 41 (12): 1169–1177. doi: 10.1001/archpsyc.1984.01790230055009.
  26. 26.
    Mottaghipour Y, Pourmand D, Maleki H, Davidian L (2001) Expressed emotion and the course of schizophrenia in Iran. Soc Psychiatry Psychiatrepidemiol 36:195–199CrossRefGoogle Scholar
  27. 27.
    Parker G, Johnson P, Hayward L (1988) Parental expressed emotion as a predictor of relapse. Arch Gen Psychiatry 45:806–813CrossRefPubMedGoogle Scholar
  28. 28.
    Bebbington P, Kuipers L (1994) The predictive utility of expressed emotion in schizophrenia: an aggregate analysis. Psychol Med 24:707–712CrossRefPubMedGoogle Scholar
  29. 29.
    Jaferi SZ (1997) Cultural analysis of expressed emotion construct. Dissertation, Government College University, LahoreGoogle Scholar
  30. 30.
    Barrelet L, Ferrerol L, Giddey CG, Pellizzer G (1990) Expressed emotion and first admission schizophrenia nine-month follow-up in a French cultural environment. Br J Psychiat 156:357–362CrossRefGoogle Scholar
  31. 31.
    Lukoff D, Nuechterlein KH, Ventura J (1986) Manual for expanded brief psychiatric rating scale. Schizophr Bull 12:594–602Google Scholar
  32. 32.
    First MB, Spitzer RL, Gibbson M, Williams JBW (1995) Structured clinical interview for DSM-1V Axis 1 disorders-patient edition. Biometrics Research Department, New York State Psychiatric Institute, New YorkGoogle Scholar
  33. 33.
    Sadiq S, Suhail K (2013) Relationship of expressed emotion with burden of care and health of caregivers of patients with schizophrenia. Pakistan J Soc Clinl Psychol 11(1):3–10Google Scholar
  34. 34.
    Ng RMK, Mui J, Cheung HK, Leung SP (2001) Expressed emotion and relapse of schizophrenia in Hong Kong. Hong Kong J Psychiatry 11(1):4–11Google Scholar
  35. 35.
    Parker G, Hadzi-Pavlovic D (1990) Expressed emotion as a predictor of schizophrenic relapse: an analysis of aggregated data. Psychol Med 20(4):961–965CrossRefPubMedGoogle Scholar
  36. 36.
    Ivanović M, Vuletić Z, Bebbington P (1994) Expressed emotion in the families of patients with schizophrenia and its influence on the course of illness. Soc Psychiatry Psychiatr Epidemiol 29:61–65PubMedGoogle Scholar
  37. 37.
    Weisman AG, Kymalainen JA, RosalesGA, Armesto, JC (2007) Expressed emotion and interdependence in White and Latino/Hispanic family members of patients with schizophrenia. Psychiatry Res 151(1–2):107–113. doi: 10.1016/j.psychres.2006.11.007 CrossRefGoogle Scholar
  38. 38.
    Harrison CA, Dadds MR, Smith G (1998) Family caregivers’ criticism of patients with schizophrenia. Psychiatr Serv 49:918–924CrossRefPubMedGoogle Scholar
  39. 39.
    Vaugh CE, Leff J (1976) The influence of family and social factors on the course of psychiatric illness: a comparison of schizophrenic and depressed neurotic patients. Br J Psychiatry 129:125–137CrossRefGoogle Scholar
  40. 40.
    Ito J, Oshima I (1995) Distribution of EE and its relationship to relapse in Japan. Int J Ment Health 24(2):23–37CrossRefGoogle Scholar
  41. 41.
    López SR, Hipke KN, Antonio JP, Jenkins JH, Karno M, Vaughn C, Snyder KS (2004) Ethnicity, expressed emotion, attributions, and course of schizophrenia: family warmth matters. J Abnorm Psychol 113(3):428–439. doi: 10.1037/0021-843X.113.3.428 CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2017

Authors and Affiliations

  1. 1.Department of PsychologyGovernment College UniversityLahorePakistan
  2. 2.Surrey Mental Health and Substance Use ServicesSurreyCanada
  3. 3.Department of PsychologyAustralian Catholic UniversityFitzroyAustralia
  4. 4.ORYGEN Youth Health Research Centre, Centre for Youth Mental HealthUniversity of MelbourneParkvilleAustralia

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