Cultural specificity of emotional overinvolvement : a systematic review

Understanding cross-cultural aspects of emotional overinvolvement (EOI) on psychosis outcomes is important for ensuring cultural appropriateness of family interventions. This systematic review explores whether EOI has similar impact in different cultural groups and whether the same norms can be used to measure EOI across cultures. Thirty-four studies were found that have investigated the impact of EOI on outcomes across cultures or culturally adapted EOI measures. The relationship between high EOI and poor outcome is inconsistent across cultures. Attempts to improve predictive ability by post hoc adjustment of EOI norms have had varied success. Few studies have attempted a priori adaptations or development of culture-specific norms. Methodological differences such as use of different expressed emotions (EE) measures and varying definitions of relapse across studies may explain a lack of EOI outcome relationship across cultures. However, our findings suggest that the construct and measurement of EOI itself are culture-specific. EOI may not necessarily be detrimental in all cultures. The effect of high EOI may be moderated by the unexplored dimension of warmth and high levels of mutual interdependence in kin relationships. Researchers should reevaluate the prevailing concepts of the impact of family relations on the course and outcome of psychotic disorders, specifically focusing on the protective aspects of family involvement. Clinically, family interventions based on EE reduction should take cultural differences into account when treating families from different ethnocultural groups

Expressed emotion and the course of schizophrenia in Pakistan

Purpose: Aim of the study is to evaluate the predictive power of Expressed Emotion in Schizophrenia relapse in Pakistan. Method: 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. Results: 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. Conclusions: 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

Rates of expressed emotions in Pakistani relatives of patients with schizophrenia

Background: Studies have reported substantial cross-cultural variations in rates of Expressed Emotions (EE) in relatives of patients with schizophrenia. As a first attempt from Pakistan, this study aimed to measure the components of EE among relatives of patients with schizophrenia in a different socio-cultural set-up. Method: Thirty-two key family members were interviewed using the Camberwell Family Interview (CFI) and Five Minute Speech Sample (FMSS). Results: Seventy-five percent of the family members appeared to be high EE with the majority (59%) rated so on the basis of hostility alone. Moreover, symptomatic behavior of the patient contributed more to the rating of relatives' hostility. Pakistani relatives showed higher levels of emotional over-involvement and hostility as compared to many other cultures. In comparison to CFI, the FMSS showed lower sensitivity for identifying high EE relatives, thus it may not be very suitable to use on its own in Pakistan for cultural reasons. Limitations: Lack of follow-up data and small sample size limit the scope of the study. Conclusions: Pakistani relatives appeared to be more hostile yet emotionally over-involved and warm toward their sick relatives as compared to the households reported in many previous studies. Psycho-educational programs need to be initiated for the concerned families to reduce their level of hostility. Outcome studies are also warranted in order to understand any link between high EE and relapse of schizophrenia in Pakistan

Development of culturally-specific family criticism scale and emotional over-involvement scale

The current study was conducted to develop the indigenous scales of family criticism and emotional over involvement in Pakistani community in the context of expressed emotion theory. To generate items for the scales, four focus groups were conducted with students, housewives, class II, and class IV workers. To establish the psychometric properties, these scales were administered to a sample of 500 participants belonging to different socio-economic status, professions, residential areas, and both genders. Exploratory Factor Analysis generated two factors for Perceived Criticism Scale namely Cultural and Religious Aspects of Criticism and Gender Related Criticism and three factors of Emotional Over-involvement Scale namely Self Sacrificing Behavior, Overprotective Behavior, and Cultural Conceptualization of Emotional Over-involvement. Reliability and factor analyses of both scales indicated that these scales are reliable and valid to measure family criticism and emotional over-involvement in social interactions of Pakistani families

Continuing Bonds in Bereaved Pakistani Muslims: Effects of Culture and Religion

This study explores the bereavement process and continuing bond in Pakistani Muslims with the focus on how culture and religion influence these processes. Ten participants were interviewed and their transcribed interviews were analyzed using a grounded theory approach. Three main domains were identified from the narratives expressed by the participants: death and the process of grieving, continuing the link with the deceased, and influencing agents. The findings indicated that Pakistani Muslims maintained their link with the deceased through cultural and religious rituals, such as performing prayers, reciting holy verses, talking and dreaming about the deceased, doing charity, visiting graves, and arranging communal gatherings. The prime purpose of many of these practices was the forgiveness of the deceased. Grief reactions seemed to be determined by the nature of death, prior relationships with the deceased, reaction of society and gender of the bereaved. Religion provided a strong basis for coping and adjustment of the bereaved, through rationalizing and accepting the death. This study has important implications for counselors and family therapists who can use religious affiliations to reduce the impact of loss and complicated bereavement.This study explores the bereavement process and continuing bond in Pakistani Muslims with the focus on how culture and religion influence these processes. Ten participants were interviewed and their transcribed interviews were analyzed using a grounded theory approach. Three main domains were identified from the narratives expressed by the participants: death and the process of grieving, continuing the link with the deceased, and influencing agents. The findings indicated that Pakistani Muslims maintained their link with the deceased through cultural and religious rituals, such as performing prayers, reciting holy verses, talking and dreaming about the deceased, doing charity, visiting graves, and arranging communal gatherings. The prime purpose of many of these practices was the forgiveness of the deceased. Grief reactions seemed to be determined by the nature of death, prior relationships with the deceased, reaction of society and gender of the bereaved. Religion provided a strong basis for coping and adjustment of the bereaved, through rationalizing and accepting the death. This study has important implications for counselors and family therapists who can use religious affiliations to reduce the impact of loss and complicated bereavement

Ethnographic analysis of expressed emotions in Pakistani families of patients with schizophrenia

Family expressed emotions (EE) have been found to be closely linked with the course of the disorder in patients with schizophrenia. Despite substantial cross-cultural differences in rates and impact of EE, a qualitative understanding of the construct is missing in relevant literature. This work was undertaken in Pakistan to understand the indigenous expression of emotional overinvolvement, criticism, and hostility as the primary components of the construct. We transcribed and conducted content analysis on the audio-recorded Camberwell Family Interviews of sixty-four caregivers to search the statements indicating these three elements. The frequency of statements showing overinvolved behavior surpasses all other accounts indicating criticism or hostility. Although many emotionally overinvolved behaviors are culturally relevant, some behaviors of the relatives, particularly of mothers, are above and beyond the cultural expectations. Outcome studies are warranted to determine whether extreme sacrificing and devoted behavior is pathological or a part of the culture. Criticism is mostly directed to socially objectionable behavior followed by personality traits of the patients. The higher frequency of hostility may be explained by specific socio-cultural factors. This ethnographic analysis shows that expressed emotions is not a culture specific construct. However, cultural distinctive patterns of emotional overinvolvement and critical attitude may exist across cultures

Cultural differences in positive psychotic experiences assessed with the Community Assessment of Psychic Experiences-42 (CAPE-42):a comparison of student populations in the Netherlands, Nigeria and Norway

BACKGROUND: Previous studies have suggested that culture impacts the experience of psychosis. The current study set out to extend these findings by examining cultural variation in subclinical positive psychotic experiences in students from The Netherlands, Nigeria, and Norway. Positive psychotic experiences were hypothesized to (i) be more frequently endorsed by, and (ii) cause less distress in Nigerian vs. Dutch and Norwegian students. METHODS: Psychology students, aged 18 to 30 years, from universities in the Netherlands (n = 245), Nigeria (n = 478), and Norway (n = 162) were assessed cross-sectionally with regard to the frequency of subclinical positive psychotic experiences and related distress, using the Community Assessment of Psychic Experiences (CAPE-42). Multi-group confirmatory factor analysis and multivariate analysis of covariance were performed to assess measurement invariance of the positive symptom dimension (CAPE-Pos) and compare mean frequency and associated distress of positive psychotic experiences across study samples. RESULTS: Only CAPE-Pos items pertaining to the dimensions 'strange experiences' and 'paranoia' met assumptions for (partial) measurement invariance. Frequencies of these experiences were higher in the Nigerian sample, compared to both the Dutch and Norwegian samples, which were similar. In addition, levels of experience-related distress were similar or higher in the Nigerian sample compared to respectively the Dutch and Norwegian samples. CONCLUSION: Although positive psychotic experiences may be more commonly endorsed in non-Western societies, our findings do not support the notion that they represent a more benign, and hence less distressing aspect of human experience. Rather, the experience of psychotic phenomena may be just as, if not more, distressing in African than in European culture. However, observed differences in CAPE-Pos frequency and distress between samples from different cultural settings may partly reflect differences in the measure rather than in the latent trait. Future studies may therefore consider further cross-cultural adaptation of CAPE-42, in addition to explicitly examining cultural acceptance of psychotic phenomena, and environmental and other known risk factors for psychosis, when comparing and interpreting subclinical psychotic phenomena across cultural groups