Verbal Interactions in the Families of Schizophrenic and Bipolar Affective Patients

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1 Page 1 of 16 Journal of Abnormal Psychology May 1995 Vol. 104, No. 2, by the American Psychological Association For personal use only--not for distribution. Verbal Interactions in the Families of Schizophrenic and Bipolar Affective Patients David J. Miklowitz Department of Psychology University of Colorado at Boulder Michael J. Goldstein Department of Psychology and Department of Psychiatry and Biobehavioral Sciences University of California, Los Angeles Keith H. Nuechterlein Department of Psychiatry and Biobehavioral Sciences University of California, Los Angeles ABSTRACT Do verbal interactions between psychiatric patients and family members covary with the diagnosis of the patient? This study compared relatives (usually parents) of schizophrenic ( n = 42) and bipolar ( n = 22) patients on affective style (AS) or emotional verbal behavior toward patients in family interaction. Patients were compared on coping style or verbal interactional behavior toward relatives. Relatives of schizophrenic patients made more negative AS (particularly intrusive) statements to patients than relatives of bipolar patients. Schizophrenic patients made fewer supportive statements and more self-denigrating statements to relatives than bipolar patients. Among families of bipolar patients, negative AS in relatives was associated with oppositional, "refusing" styles in patients. Implications for psychosocial interventions with these disorders are discussed. This research was supported by National Institute of Mental Health Grants MH43931, MH42556, MH08744, MH37705, MH14584, and MH30911; a grant from the John D. and Catherine T. MacArthur Foundation on Risk and Protective Factors in the Major Mental Disorders; and a Young Investigator Award from the National Alliance for Research on Schizophrenia and Depression. We thank Jeri Doane, Dorothy Feingold, David Fogelson, Michael Gitlin, Sun Hwang, Charles Judd, David Lukoff, Jim Mintz, Karen Snyder, Angus Strachan, Joseph Ventura, and Sibyl Zaden for their assistance. Correspondence may be addressed to David J. Miklowitz, Department of Psychology, University of Colorado at Boulder, Muenzinger Building, Boulder, Colorado, Received: July 13, 1993 Revised: August 20, 1994 Accepted: August 20, 1994 Evidence indicates that emotional qualities of the family environment are significant prospective predictors of the course of various psychiatric disorders, even for those disorders for which genetic and other biological variables provide powerful etiological explanations. Specifically, critical, hostile, or emotionally overinvolved attitudes held by key relatives about a hospitalized patient, termed high expressed emotion (EE), are associated with high rates of patient relapse over 9-month to 1-year periods in schizophrenia ( Kavanagh, 1992 ; Parker & Hadzi-Pavlovic, 1990 ), bipolar disorder

2 Page 2 of 16 ( Miklowitz, Goldstein, Nuechterlein, Snyder, & Mintz, 1988 ; Priebe, Wildgrube, & Muller- Oerlinghausen, 1989 ), and unipolar depressive disorder ( Hooley, Orley, & Teasdale, 1986 ; Vaughn & Leff, 1976 ). Likewise, negative parent-to-patient verbal interactional behaviors (i.e., criticism, intrusiveness) during the postdischarge period, termed negative affective style (AS), prospectively predict relapses of schizophrenia ( Doane, Falloon, Goldstein, & Mintz, 1985 ) and bipolar disorder ( Miklowitz et al., 1988 ). Levels of EE attitudes and AS behaviors are usually intercorrelated but do not completely overlap in parents of schizophrenic patients ( Miklowitz et al., 1989 ; Miklowitz, Goldstein, Falloon, & Doane, 1984 ; Strachan, Leff, Goldstein, Doane, & Burtt, 1986 ). Despite an extensive literature correlating family attitudes (EE) and interactional behaviors (AS) with the course of patients' psychiatric disorders, little is known about whether their development varies as a function of the patient's diagnostic status. EE and AS may reflect some of the natural emotional reactions of family members to the onset of an acute episode of psychiatric disorder in another family member, as well as the difficulties that arise when this family member, who may still have residual symptoms, returns from the hospital to the home ( Kavanagh, 1992 ; Nuechterlein, Snyder, & Mintz, 1992 ). These family attributes have been conceptualized as generalized stressors that in conjunction with other biological and social factors overwhelm a biologically vulnerable family member and contribute to recurrences of his or her disorder ( Nuechterlein & Dawson, 1984 ; Zubin & Spring, 1977 ). 1 However, few studies have examined whether high levels of EE or AS are more frequently associated with certain disorders like schizophrenia or whether the development of these attributes is equally common in families coping with other recurrent disorders that are stressful to significant others. In a previous study ( Miklowitz, Goldstein, Nuechterlein, Snyder, & Doane, 1987 ), we found that high- and low-ee attitudes in parents were distributed equally among recent onset, hospitalized schizophrenic and bipolar, manic patients. Likewise, Vaughn and Leff (1976) found that parents of hospitalized schizophrenic patients did not differ from spouses of hospitalized depressed patients in the number of EE criticisms. Thus, high-ee attitudes may reflect a diagnostically nonspecific tendency for some family members to react with negativity or overconcern to an acutely ill family member. However, interactional behavior as assessed during a period of full or partial remission of the patient's disorder may be associated with a different cluster of factors, including the diagnosis of the patient, level or type of residual symptoms, and styles of interacting with family members during the aftercare period. In this study, we examined whether the verbal interactional behavior of relatives (AS) varies with the form of an index patient's psychiatric disorder. Relatives of patients who had recent episodes of schizophrenic or bipolar, manic disorder for which they were hospitalized were asked to discuss with the patient and attempt to resolve a series of family problems. Levels of AS in relatives were then compared across the two diagnostic groups. Conducting these assessments during the posthospital period allowed us to compare the family interactional styles that accompany a period of partial remission in the patient. A second objective was to identify the correlates of variability in the interactional (AS) behavior of relatives of patients with these diagnoses. We hypothesized that relatives' AS behavior would covary with two patient attributes that are likely to be correlated with diagnosis: (a) the patient's level or type of residual symptoms at the time of these family discussions, and (b) the patient's styles of interacting with relatives. Because schizophrenic and manic patients are likely to display different patterns of residual symptoms during the postdischarge period, relatives may show interactional styles that are congruent with these symptom patterns. For example, schizophrenic patients who are severely

3 Page 3 of 16 withdrawn and have severe negative symptoms during the posthospital period may prompt "mind reading" or intrusiveness from relatives, an interactional process that might be less characteristic of families of bipolar patients. We also predicted that patients' interactional behaviors with relatives would be correlated with these relatives' response patterns. Strachan, Feingold, Goldstein, Miklowitz, and Nuechterlein (1989) developed the coping style (CS) coding system to measure the way in which patients elicit or respond to relatives' AS behaviors during family discussions. In an initial examination of the schizophrenia sample used in the present study, Strachan et al. found that schizophrenic patients showed two primary coping styles when interacting with relatives who showed high levels of negative AS: internalizing, self-denigrating "complementary" styles; and (less consistently) externalizing, blaming "symmetrical" styles. However, it is unclear whether these bidirectional patterns of interaction vary with the patient's diagnosis. Because bipolar patients often achieve more complete posthospital symptom remissions than schizophrenic patients, they may exhibit greater positive and fewer internalizing or externalizing behaviors when interacting with their relatives. In turn, their relatives may be less likely to show critical or intrusive behaviors in these interactions. Thus, the present study had four objectives: (a) to compare the AS-interactional behavior of relatives of schizophrenic and bipolar patients during the postdischarge period; (b) to determine whether intergroup differences in AS are a function of the concurrent symptom status of the index patient; (c) to compare the interactional behavior (CS) of patients from these two diagnostic groups; and (d) to examine which reciprocal transactional (AS CS) patterns characterize families coping with these two disorders. Participants Method Participants were recruited from the inpatient units of each of four psychiatric facilities serving the greater Los Angeles area (University of California, Los Angeles [UCLA] Neuropsychiatric Hospital, Camarillo State Hospital, Olive View Medical Center, and Harbor/UCLA Medical Center) or from among outpatients referred to the UCLA Neuropsychiatric Hospital during or shortly after a psychotic episode. Patients in the schizophrenia and bipolar samples were recruited for separate longitudinal studies, as explained below. All participants met the following inclusionary criteria: (a) for the schizophrenia sample, a Research Diagnostic Criteria (RDC; Spitzer, Endicott, & Robins, 1978 ) diagnosis of schizophrenic disorder or schizoaffective, mainly schizophrenic disorder, and for the bipolar sample, an RDC diagnosis of manic disorder or schizoaffective, mainly affective manic disorder; (b) age between 18 and 45 years; (c) no evidence of mental retardation or neurological disorder; (d) no evidence of significant and habitual abuse of drugs or alcohol in the prior 6 months and no evidence that substance abuse clouded the RDC diagnosis; (e) Anglo American, Native American, acculturated Hispanic or Asian origin, with English fluency; (f) illness of recent onset; and (g) willingness and ability to give informed consent. Recruitment of schizophrenic patients and families. Patients in the schizophrenia sample were recruited for a longitudinal study titled "Developmental Processes in Schizophrenic Disorders" ( Nuechterlein, Dawson, et al., 1992 ). Patients and their key relatives gave written informed consent for their own participation using forms approved by the UCLA Institutional Review Board (IRB) and were provided additional verbal information regarding

4 Page 4 of 16 the research project. Oral information included specific details of the medication treatment to be used during the research project period and of alternative treatments available elsewhere than in this research program. Information about the project, including use of antipsychotic medications, the nature of schizophrenia, and typical relapse rates and illness courses were also provided in a family education program offered to all key relatives. Regular reviews of human subjects issues and approvals of consent forms were completed by the local IRB and by NIMH [National Institute of Mental Health] reviewers and site visitors. As requested during these reviews, written informed consent forms were revised several times during the course of the research to provide further information in writing regarding project procedures, medications, and their benefits and risks. Nonetheless, in response to complaints of family members of two patient subjects, the Office for Protection from Research Risks at the National Institutes of Health initiated a comprehensive review, which resulted in additional changes in the consent forms in At each step we added to written consent forms whatever information was requested by the relevant reviewing agency. The modifications in consent forms primarily involved specification in writing of information provided earlier in individual and group contacts with patients and relatives or new information that was generated during the course of the research itself. Approximately 5 6 weeks after patients were recruited into the "Developmental Processes" project, they and their family members were informed by project staff of a separate study of family relationships conducted by an affiliated research group. If patients and their relatives expressed a willingness to be contacted by this affiliated group, they were telephoned by this group and the study procedures were described in detail. If they continued to express a willingness to participate, they were invited to an outpatient family assessment session from which the key family interactional measures (AS and CS) were derived (see Procedures below). Patients and relatives gave separate written informed consent for this assessment session. Of the first 45 schizophrenic patients and families recruited for the "Developmental Processes" study, 42 consented to participate in this affiliated family study, and 3 refused participation. Recruitment of bipolar patients and families. Patients in the bipolar sample were recruited for a separate naturalistic study of family factors in the longitudinal course of bipolar disorder ( Miklowitz et al., 1988 ). Although the bipolar patients originated at the same hospital sites as the schizophrenic patients, they were recruited as inpatients directly into this longitudinal study rather than the "Developmental Processes" project. The study's staff used procedures similar to those used with the schizophrenic patients and families to explain the outpatient family assessment procedures to and obtain written informed consent from bipolar patients and their families. Of 24 bipolar patients and families recruited for this longitudinal study, 22 consented to the family assessment session and 2 refused. Sample characteristics. This sample of schizophrenic ( n = 42) and bipolar ( n = 22) patients included relatively young (mean age = 22.1 years, SD = 3.4), recent-onset patients (mean illness duration including prodromal periods = 10.3 months, SD = 8.1) from a wide range of social classes, with an average Hollingshead Redlich (1958) class of 2.7 ( SD = 1.2). Of the 64 patients, 46 (72%) were men and 18 (28%) were women. Relatives were most often parents ( n = 61 families), but in 2 families they were spouses and in 1 family, a sibling. All relatives had been in regular contact with the patient for at least one of the 3 months prior to the onset of the index episode.

5 Page 5 of 16 The two diagnostic groups were successfully matched on age, socioeconomic status, ethnicity, family composition (dual parent, single parent, spousal, or sibling), and illness duration. The schizophrenia sample had a greater proportion of male patients (83%) than the bipolar sample (50%), χ 2 1, N = 64 = 7.9, p <.005. Compared with the schizophrenic patients, the bipolar patients had more years of education (bipolar patients, M = 13.0 years, SD = 1.1; schizophrenic patients, M = 12.0 years, SD = 1.8), F (1, 62) = 6.2, p <.02; younger ages at illness onset (bipolar patients, M = 19.7, SD = 2.7; schizophrenic patients, M = 21.5, SD = 3.4), F (1, 62) = 4.3, p <.05; and more hospitalizations prior to the index episode (bipolar patients, M = 1.9, SD = 3.3; schizophrenic patients, M < 1, SD = 1.1), F (1, 60) = 5.6, p <.025. At the time of the outpatient family assessment session, schizophrenic patients were in the process of being pharmacologically stabilized on a standardized starting dose (12.5 mg every 2 weeks) of injectable fluphenazine decanoate (Prolixin). Bipolar patients were being stabilized on lithium carbonate or lithium with adjunctive medications (i.e., phenothiazines, carbamazepine, antidepressants). Procedures Diagnosis. All patients were interviewed during or shortly after resolution of the index episode by trained diagnosticians who used an expanded version of the Present State Exam (PSE; Nuechterlein, Dawson, et al., 1992 ; Wing, Cooper, & Sartorius, 1974 ) that enabled diagnosis using the RDC and the Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.; American Psychiatric Association, 1987 ). Schizophrenic patients met the RDC criteria for schizophrenic disorder ( n = 36) or schizoaffective, mainly schizophrenic disorder ( n = 6). Bipolar patients met the RDC criteria for manic disorder ( n = 12) or schizoaffective, mainly affective manic disorder ( n = 10). Information was also gathered at this time about the patient's psychiatric and social history. Diagnosticians completed a 10-week PSE and RDC training course prior to collecting data for this study. Each diagnostician achieved minimum interrater reliability coefficients with a criterion rater of 85% for the presence of and 95% for the absence of PSE items relevant to the diagnoses of schizophrenia and affective disorders, calculated from a minimum of 10 reliability interviews. Diagnosticians met these criteria throughout the study. Family interaction assessment. The purpose of the family assessment session, conducted on an outpatient basis about 5 6 weeks after the patient was initially recruited into the study, was to sample the emotional and verbal behavior of relatives (AS) and patients (CS) during a videotaped family interaction task. This task, described in detail elsewhere ( Miklowitz et al., 1984 ), consisted of two 10-min problem-solving discussions between the patient and relative(s), with the experimenter absent. Discussions focused on problems identified by the patient or relative in individual interviews. Affective style in relatives. Verbatim transcripts of these 10-min interactions were coded for AS by a criterion rater and a trained rater who were blind to patient diagnoses (schizophrenic vs. bipolar, manic). Statements by relatives were tabulated if they met criteria for one of the following codes: (a) critical statements, which fell into two categories: benign or situation-specific criticisms (e.g., "You have a bad attitude about

6 Page 6 of 16 school") and harsh or personal criticisms, which could be of a villifying, character-assassinating type (e.g., "You are a lazy person") or of a guilt-inducing type (e.g., "You make life difficult for all of us"); (b) intrusive statements, in which the relative implies a knowledge of the patient's internal feelings or motives, beyond what the patient has actually stated (e.g., "You're not angry, you're depressed"); or (c) supportive statements (e.g., "You do that well"). Interrater reliability between the criterion and the trained rater was calculated using Cohen's (1960) kappa; calculations were based on 48 independently rated interaction transcripts from this sample of schizophrenic and bipolar patients. To estimate kappa conservatively, we eliminated from consideration agreements between the raters on code nonoccurrence (i.e., relatives' statements that both raters agreed did not meet criteria for any AS code). Instead, kappas were calculated from those instances in which one or both raters felt that an AS code was applicable. The overall kappa for the AS system, calculated across the four AS codes considered simultaneously in one matrix, was.90 ( p <.0001). Kappas for each individual AS code (calculated from 2 2 matrices in which were plotted raters' agreements vs. disagreements on the discrimination between this AS code and all other AS codes that might have applied to relatives' statements) were as follows: benign criticisms,.93; harsh criticisms,.95; intrusive statements,.95; and support,.91 (all p s <.0001). Coping styles in patients. Two raters applied the CS system to the typewritten interaction transcripts in order to classify the verbal interactional behavior of patients. The raters had received extensive training in the system and were blind to patients' diagnoses. Only patients' statements that met criteria for a specific CS code were tabulated. CS codes that were considered positive in emotional tone included: (a) autonomy statements, indicating that the patient has a clear determination to achieve a certain goal independent of the relative (e.g., "I'll see a job counselor tomorrow"); (b) self-affirming statements, indicating that the patient views himself or herself as competent, mature, likeable, or worthwhile (e.g., "I'm good at making friends"); or (c) support statements that convey concern or empathy for relatives (e.g., "I know that was difficult for you and dad"). Negative CS codes included: (a) critical statements about relatives, either of a specific (e.g., "You haven't helped me in my schoolwork") or a harsh, personal type (e.g., "You are not a good parent"); (b) refusals to comply with a request or demand made by a relative (e.g., "No, I won't do that") or to share in a joint activity (e.g., "I won't go with you to the wedding"); or (c) self-denigrating statements, in which the patient conveys criticism of or dissatisfaction or unhappiness with himself or herself or his or her behavior (e.g., "I feel like I don't deserve your help"). On the basis of 36 independently rated interaction transcripts, the two raters achieved an overall interrater reliability (kappa) coefficient for the CS system of.70 ( p <.0001), calculated across the six CS codes considered simultaneously. Kappas for the individual CS codes, calculated in the same manner as for the AS codes, were as follows: autonomy,.83; self-affirmation,.73; support,.83; criticism,.86; refusal,.83; and self-denigration,.68 (all p s <.0001). Concurrent symptom status. Patients were interviewed during the family assessment session or within 1 week of this session to document their level of symptoms over the prior 2 weeks. They were then rated on an expanded version of the Brief Psychiatric Rating Scale (BPRS; Lukoff, Nuechterlein, & Ventura, 1986 ; Overall & Gorham, 1962 ). All interviews and ratings were conducted by staff members who were blind to

7 Page 7 of 16 the AS and CS data and who had previously completed a 3-month BPRS workshop and attained minimum interrater reliability coefficients of.80 (intraclass r, calculated across BPRS subscales) with a criterion rater. Data Transformation Results When two parents participated in the two 10-min interaction tasks, their individual AS scores (i.e., number of critical, intrusive, or supportive statements) were summed over the two tasks to form family AS scores. When only one relative participated, that individual's scores served as the family's scores. Patients' CS scores (e.g., number of autonomy statements) were also summed over the two interactions to form total scores. There were no differences between single- and dual-parent families on any of these AS or CS scores (all p s >.10). Certain of the AS and CS scores were positively, although moderately, correlated with the amount of typewritten speech produced by relatives and patients, respectively. Relatives of schizophrenic and bipolar patients did not differ on the amount of speech produced during the two interaction tasks, F (1, 62) = 0.58, p >.10. However, bipolar, manic patients produced almost twice as many lines of speech ( M = 113.6, SD = 51.2) as schizophrenic patients ( M = 65.8, SD = 40.1), F (1, 62) = 16.9, p < To adjust for differences in amount of speech, ratios were formed of family AS or patient CS scores to the amount of speech produced by relatives or patients. Ratio scores were highly correlated with their uncorrected counterparts (mean r =.80) but not with the amount of speech by relatives or patients (mean r =.10). Effects of Symptom Status It was first necessary to determine whether the schizophrenic and bipolar patients were in equivalent symptomatic states at the time of the postdischarge family assessments (as measured by BPRS ratings). There were no diagnostic differences on BPRS Total Psychopathology scores, F (1, 62) = 1.3, p >.10. However, bipolar patients were rated higher than schizophrenic patients on two of the five standard BPRS factors ( Guy, 1976 ): Activation (bipolar patients, M = 1.77, SD = 0.5; schizophrenic patients, M = 1.26, SD = 0.3), F (1, 62) = 23.9, p <.0001; and Hostility Suspiciousness (bipolar patients, M = 1.95, SD = 0.6; schizophrenic patients, M = 1.45, SD = 0.6), F (1, 62) = 9.1, p <.005. The groups did not differ on BPRS Anergia, Thought Disturbance, or Anxious Depression factor scores (all p s >.10). In the sample as a whole ( N = 64), BPRS Activation and Hostility Suspiciousness scores bore relatively weak relations to relatives' AS and patients' CS variables. Of 20 relationships examined (4 AS variables and 6 CS variables correlated with patient BPRS Activation and BPRS Hostility Suspiciousness scores), only 2 were statistically significant. Specifically, patients with higher BPRS Hostility Suspiciousness scores made more CS criticisms of their relatives, r (64) =.26, p <.05, and refusals to comply with relatives' requests or demands, r (64) =.31, p <.05. The lack of a general pattern of statistically reliable relations between relatives' AS or patient CS scores and patient BPRS scores did not rule out the possibility that subtle symptom differences between patients (a) affected the interactional behaviors of relatives or patients and (b) explained differences between the diagnostic groups on these behaviors. Therefore, to be conservative, BPRS Activation and Hostility Suspiciousness scores were used as covariates in the diagnostic group

8 Page 8 of 16 comparisons on AS and CS below. Comparisons of Relatives' Affective Style Scores First, we compared relatives from the two groups on a total negative AS score (the sum of all critical [benign and harsh] and intrusive statements made by relatives), which in prior samples of schizophrenic patients was found to be a reliable indicator of total affective negativity within the family milieu ( Miklowitz et al., 1984 ; Strachan et al., 1986 ). Using this total negative AS score as the dependent variable and patient BPRS Activation and Hostility Suspiciousness scores as covariates, we performed an analysis of covariance (ANCOVA) and found that relatives of schizophrenic patients made almost twice as many negative AS statements as relatives of bipolar patients, F (1, 60) = 7.2, p <.01 ( Table 1 ). To examine this diagnostic difference further, a multivariate analysis of covariance (MANCOVA) was conducted comparing relatives from the two groups on the individual AS variables (benign criticism, harsh criticism, intrusion, and support) considered simultaneously. This MANCOVA revealed a main effect of diagnosis after BPRS scores were covaried, Wilks's F (4, 57) = 2.8, p <.05 ( Table 1 ). Univariate ANCOVAs revealed that this omnibus difference was primarily due to the greater number of AS intrusive statements ("mind reading") among the relatives of schizophrenic patients, F (1, 60) = 9.4, p <.005, and to a nonsignificant extent, of benign criticisms, F (1, 60) = 3.3, p <.10. Relatives from the two groups did not differ on the number of AS harsh criticisms or support statements (for both, p >.10). Comparisons of Patients' Coping Style Scores Using a MANCOVA, in which BPRS Activation and Hostility Suspiciousness scores were covaried, we compared patients from the two diagnostic groups on the six CS variables described above. The main effect of diagnosis was significant in this MANCOVA, Wilks's F (6, 55) = 2.5, p <.05. ANCOVAs (see Table 1 ) revealed that bipolar patients made more statements of support for their relatives than schizophrenic patients, F (1, 60) = 4.4, p <.05, whereas schizophrenic patients made more self-denigrating statements (e.g., "I'm not good with people") than bipolar patients, F (1, 60) = 3.9, p =.05. The other CS codes did not distinguish between the groups (all p s >.10). Evaluating the Homogeneity of Regression Assumption To determine whether the homogeneity of regression assumption ( Tatsuoka, 1971 ) was warranted for the above ANCOVA and MANCOVA tests, we investigated whether the relations of the two BPRS covariates to relatives' AS and patients' CS scores were comparable across the schizophrenic and bipolar groups. In two separate multivariate analyses of variance (MANOVAs), we examined the interactions between diagnosis and patients' BPRS Activation factor scores, and between diagnosis and BPRS Hostility Suspiciousness factor scores, in predicting (a) AS scores (considered simultaneously) and (b) CS scores (considered simultaneously). Only one of these four Diagnosis BPRS Factor Score interactions was significant, that between diagnosis and BPRS Hostility Suspiciousness in predicting relatives' AS scores, F (4, 55) = 3.2, p <.025. Further examination of this interaction revealed that diagnosis interacted with BPRS Hostility Suspiciousness scores in predicting relatives' scores on only one specific AS code, intrusive statements, F (1, 58) = 8.2, p <.01. BPRS Hostility Suspiciousness scores were significantly correlated with relatives' AS intrusive statements in the bipolar sample, r (22) =.50, p <.02, but not

9 Page 9 of 16 in the schizophrenia sample, r (42) =.17, p >.10. These results suggest that in families of bipolar but not schizophrenic patients, patients' levels of hostility suspiciousness may be significant mediators of certain types of interactional behavior (i.e., intrusiveness) in relatives, as discussed later. To determine whether the specific relationship between patient diagnosis and relatives' AS intrusive statements was an artifact of including patients' BPRS scores as covariates, a univariate analysis of variance (ANOVA) with no covariates was conducted. This ANOVA revealed a significant main effect of diagnosis on relatives' AS intrusion scores, F (1, 62) = 10.0, p <.005. Thus, relatives of schizophrenic patients made more AS intrusive statements than those of bipolar patients even when patients' symptom scores were not statistically controlled. Effects of Demographic and Illness History Variables We also examined the possibility that preexisting differences between diagnostic groups in demographic or illness variables modified the AS or CS behavior of relatives or patients. None of the following patient variables accounted for the relations between patient diagnosis and AS or CS scores when used as independent variables (for categorical patient variables) in two-way ANOVAs or as covariates (for continuous patient variables) in one-way ANCOVAs: age of the patient, gender, ethnicity, education, family composition, family socioeconomic status, duration of illness, number of hospitalizations, or age at illness onset. Reciprocal Patterns of Interaction The group comparisons on AS and CS did not clarify the issue of diagnostic differences in the reciprocity of emotional verbal behaviors between relatives and patients. Are high levels of negative AS in relatives associated with the same kinds of CS statements in schizophrenic patients as in bipolar patients? Specifically, do the higher levels of negative AS among relatives of schizophrenic patients, and the higher levels of CS self-denigration and lower levels of support expressed by these patients, suggest forms of reciprocally negative interchange in families of schizophrenic patients that are uncommon in bipolar disorder? Within-group correlations between affective style and coping style. Taking the schizophrenia sample first, we computed correlations between relatives' total negative AS scores and each of the six patient CS variables. Consistent with the MANCOVA results, schizophrenic patients with high levels of CS self-denigration tended to be paired with relatives with high total negative AS scores, r (42) =.29, p <.10 (two-tailed). Schizophrenic patients also made fewer statements of CS self-affirmation (e.g., "I know I'm a pretty good artist") when paired with relatives who had high negative AS scores, r (42) =.33, p <.05. The corresponding correlations within the bipolar sample were r (22) =.01, p >.10, and r (22) =.08, p >.10, respectively. However, tests of the statistical difference between independent correlations ( Bruning & Kintz, 1987 ) revealed that the two groups did not differ in the strength of these relations (for AS/CS selfdenigration, z = 1.1, p >.10; for AS/CS self-affirmation, z = 0.9, p >.10). How did the bipolar patients elicit (or respond to) negative AS statements by their relatives? The MANCOVA results raised the possibility that bipolar patients inhibited the negative AS behavior of their relatives by making frequent expressions of support for them. However, within the bipolar sample there was no relation between the total amount of negative AS expressed by relatives and the amount of CS support expressed by patients, r (22) =.22, p >.10. Instead, correlations between

10 Page 10 of 16 total negative AS scores and each of the remaining five patient CS scores (criticisms of relatives, refusals to comply, and self-denigrating, self-affirming, and autonomy statements) revealed a strong relation in the bipolar sample between negative AS in relatives and number of patient refusal statements (e.g., "I don't want to do that"), r (22) =.56, p <.01. In the schizophrenia sample, this same correlation was negative in direction and nonsignificant, r (42) =.23, p >.10. Between groups, the statistical difference in the magnitude and direction of this AS CS correlation was significant, z = 3.1, p <.001. Thus, schizophrenic and bipolar patients may differentially elicit or respond differently to relatives' critical and intrusive statements. Analysis of salient response strategies. The within-group correlations between AS and CS suggested that there might be two separate, independent CSs among patients: an internalizing, self-denigrating style and an externalizing, refusing style. In fact, frequencies of CS self-denigrating and refusal statements by patients were unrelated in the schizophrenia sample, r (42) =.04, p >.10, the bipolar sample, r (22) =.01, p >.10, and the full sample, r (64) =.04. Were there between-group differences in the patterning of or interplay between these two types of CS behavior that might explain how patients in each group elicit or respond to relatives' AS? Do schizophrenic patients show a predominance of self-denigrating over refusal statements when interacting with relatives with high levels of negative AS? Do bipolar patients show a predominance of refusal over self-denigrating statements with their high AS relatives? We constructed a "salient response strategy" difference score for each patient by subtracting his or her raw (uncorrected) number of refusal statements from his or her raw number of self-denigrating statements. A positive difference score indicated that the patient made more self-denigrating than refusal statements, whereas a negative score indicated the reverse. This difference score closely followed a normal distribution in this sample. It appeared unnecessary to correct these scores for amount of patient speech because (a) they reflected differences in the relative usage of selfdenigrating versus refusal statements within each individual patient, and (b) the correlations between these uncorrected difference scores and the amount of patient speech were nonsignificant in both diagnostic groups. A two-way ANCOVA tested the hypothesis that schizophrenic and bipolar patients showed different salient response strategies with relatives who were high in negative AS. The independent variables were diagnosis and AS (dichotomized as low vs. high on the basis of a sample median split [median = 8.7] of total negative AS scores), the covariates BPRS Activation and Hostility Suspiciousness scores, and the dependent variable, CS response strategy difference scores. Results are presented in Figure 1. The main effect of diagnosis was significant after BPRS scores were covaried, F (1, 58) = 9.8, p <.005, indicating that schizophrenic patients showed predominantly self-denigrating strategies (positive scores) and bipolar patients predominantly refusing strategies (negative scores). The main effect of AS approached but did not achieve significance, F (1, 58) = 3.1, p <.10. Finally, the interaction between diagnosis and AS was significant, F (1, 58) = 7.3, p < Tests of simple effects indicated that schizophrenic patients were more likely to show selfdenigrating strategies (positive scores) when interacting with their high AS relatives, whereas bipolar patients were more likely to show refusing strategies (negative scores) when interacting with their high AS relatives, t (30) = 2.75, p =.01. There were no diagnostic differences in patients' response strategy difference scores when relatives were low in AS, t (30) = 0.4, p >.10. 3

11 Page 11 of 16 Effects of symptoms on salient response strategies. As indicated earlier, the bipolar patients had higher BPRS Hostility Suspiciousness scores than the schizophrenic patients during this postdischarge period. Furthermore, in the bipolar sample, those patients with high BPRS Hostility Suspiciousness scores had relatives who frequently made AS intrusive statements. Were bipolar patients with refusing salient response strategies more hostile and suspicious? In the bipolar sample, CS response strategy difference scores were negatively related to BPRS Hostility Suspiciousness scores, r (22) =.44, p <.05, indicating that those bipolar patients who made more refusing than self-denigrating CS statements were more symptomatic on this BPRS dimension. This correlation was nonsignificant in the schizophrenia sample, r (42) =.10, p >.10. The difference between groups in the magnitude of these correlations approached but did not achieve statistical significance, z = 1.33, p <.10. Thus, the likelihood that bipolar patients adopt externalizing (vs. internalizing) strategies when interacting with relatives is to some degree influenced by the presence of certain residual symptoms. Discussion In this study, we examined whether relatives' AS scores and patients' CS scores derived from family problem-solving discussions covary with the diagnostic status (schizophrenic vs. bipolar) of an index patient. A primary finding was that the relatives of schizophrenic patients make more AS intrusive statements and also tend to make more benign critical statements toward the patient during the posthospital period than the relatives of bipolar patients. Intrusive and benign critical statements by relatives are relatively high base rate AS behaviors that, taken individually, are not unusually severe in content. However, when delivered frequently, these types of AS statements are possibly quite stressful to the patient, as evidenced by their longitudinal association with high relapse rates in schizophrenia ( Doane, Goldstein, Miklowitz, & Falloon, 1986 ). What are the origins of these diagnostic differences in relatives' AS behavior? Our results did not suggest that variations in relatives' AS scores were primarily a function of the patient's residual symptoms at the time the data were collected. In fact, bipolar patients were more overtly symptomatic than schizophrenic patients at this postdischarge point, and relatives of bipolar patients expressed fewer negative AS statements than did those of schizophrenic patients. Furthermore, patient diagnosis predicted relatives' AS scores when patients' concurrent symptom scores were covaried. However, schizophrenic patients often have higher levels of functional impairment associated with their symptoms than do bipolar patients ( Grossman, Harrow, Fudula, & Meltzer, 1984 ), and the interactional behavior of their relatives may in part reflect reactions to the caretaking burden associated with this impairment rather than the symptoms of schizophrenia. Diagnostic differences in relatives' AS behavior were accompanied by diagnostic differences among patients in their interactional behavior (CS) with relatives. Bipolar patients made significantly more statements of CS support for their relatives (e.g., "I know you want to help me") than schizophrenic patients, whereas schizophrenic patients made more statements of CS self-denigration (e.g., "I'm really a bother to you and dad") than bipolar patients. These group differences in CS behavior did not appear to be a function of residual symptoms of schizophrenia or affective disorder. The meaning of these group differences is not clear until one considers the different pattern of relationships between parental AS and patient CS behavior in the two diagnostic groups. Contrary to one of our initial hypotheses, the more frequent expressions of CS support by bipolar patients did not

12 Page 12 of 16 appear to inhibit the degree of AS negativity expressed by their relatives. In fact, within-group correlations between AS and CS variables, as well as analyses of "salient response strategies" that considered the patient's proportional usage of CS externalizing (i.e., refusal) versus internalizing (i.e., self-denigrating) statements, revealed that bipolar patients, notably those with high AS relatives, often took a predominantly externalizing, "refusing" stance in interactions. These patients frequently opposed the opinions, criticisms, or suggestions expressed by relatives in a "symmetrical" relational process ( Haley, 1963 ). Because the bipolar sample contained few high AS relatives, these findings should be replicated in larger, more chronic bipolar samples with more variance in relatives' AS scores. Earlier, we noted that bipolar patients spoke almost twice as often during the interactions as schizophrenic patients. Examination of the videotapes of these interactions confirmed that bipolar patients were much more assertive during family discussions than schizophrenic patients, often confronting their relatives and attempting to structure or direct the discussions. The predominance of this directive or assertive style among the bipolar patients, as well as the higher levels of support they expressed toward their relatives, may reflect more advanced social skills in the bipolar than the schizophrenic patients. Indeed, patients with affective disorders often score higher on social adjustment measures than do those with schizophrenia ( Bellack, Morrison, Mueser, & Wade, 1989 ; Grossman et al., 1984 ; Grossman, Harrow, Goldberg, & Fichtner, 1991 ). We also considered whether this directive, assertive style was a reflection of residual symptoms among the bipolar patients. BPRS Activation and Hostility Suspiciousness scores collected at the time of the interactional assessment did not readily account for the diagnostic group differences in patients' salient response strategy scores. However, patient BPRS Hostility Suspiciousness scores tended to be more strongly correlated in the bipolar than the schizophrenic sample with the degree to which patients showed refusing (relative to self-denigrating) response strategies. Thus, these assertive styles in bipolar patients may in part reflect residual symptomatic states rather than habitual styles of interacting with relatives, states that may in turn influence relatives' affective responses during these interactions (particularly their use of intrusive statements). The BPRS, a measure of clinically significant symptoms, may have actually underestimated the strength of these relations, and future studies should include measures that are also designed to quantify subclinical states. In contrast, schizophrenic patients tended to make more self-denigrating than refusal statements when interacting with relatives who were high in AS. This pairing of negative AS behaviors in relatives with "internalizing" CS behaviors in patients a pairing that was almost nonexistent in the families of bipolar patients may suggest a "complementary" relational process ( Haley, 1963 ) to which both relatives and schizophrenic patients contribute. Schizophrenic patients who make many selfdenigrating statements may suffer from low self-esteem, poor social skills, or feelings of guilt about the effects of their disorder on family members. In turn, relatives' negative AS statements may reflect reactions to these patient attributes. For example, intrusiveness or "mind-reading" by relatives may be a means of encouraging affective expression in a socially withdrawn, self-critical patient. However, self-denigration could also reflect an adaptive strategy for some patients, because these statements may inhibit further negative exchanges with relatives. It should be emphasized that not all of the schizophrenic patients showed these self-denigrating styles when interacting with relatives who made many negative AS statements. In fact, inspection of the CS data (see Table 1 ) revealed that some schizophrenic patients, like bipolar patients, may elicit or respond to criticism or intrusiveness from relatives by opposing or criticizing the relative. Schizophrenic patients' proportional use of internalizing versus externalizing CS statements may be

13 Page 13 of 16 determined by a number of factors not examined here, including attributes of the patient's personality, biological predisposition, or longstanding relationship with the relative. This study had several limitations. First, because the AS and CS coding systems do not classify each utterance made by participants, we could not use sequential analyses ( Gottman, 1987 ). Therefore, we cannot determine whether patients or relatives "drive" these interaction patterns. It is interesting that an analysis of nonverbal interactional behavior in this sample of schizophrenic patients, using a different family observational coding system that permits sequential analysis (the Category System for Partner Interactions), revealed that negative interactional sequences are equally likely to be initiated by schizophrenic patients and relatives ( Hahlweg et al., 1989 ). Second, we examined family interactions only once, during a partial remission of the patient's disorder. Furthermore, the patients' conditions were of recent onset, and family interactions may change over repeated episodes of these disorders. Studies that assess family variables across multiple patient states and that include chronic as well as recent onset patients could evaluate the stability of these interaction patterns. Our results have implications for the planning of psychosocial interventions for these patient populations. For schizophrenic patients with internalizing, self-denigrating styles, one may choose to focus on enhancing the patient's confidence and self-esteem within the family milieu, perhaps through enlisting the support of family members in helping the patient to develop assertiveness and negotiation skills. For both schizophrenic and bipolar patients who show externalizing, refusing styles, one should assess whether these styles indicate appropriate assertiveness that enhances problem-solving or a willful opposition to relatives. In the latter case, training of the patient and family in communication and problem-solving skills, which in several studies was associated with lower relapse rates in schizophrenia (for reviews, see Kavanagh, 1992 ; Strachan, 1986 ), may generate an atmosphere of mutual collaboration. The present study delineated patterns of reciprocal interaction that occur in the family environments of patients with schizophrenia and bipolar disorder. Research on the relative efficacy of family psychosocial treatments for patients with these different but comparably debilitating disorders may help to elucidate the relative malleability of these interaction patterns and whether modifying these patterns leads to improved outcomes for the patient. References American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., rev.).(washington, DC: Author) Ball, R. A., Moore, E. & Kuipers, L. (1992). Expressed emotion in community care staff: A comparison of patient outcome in a nine month follow-up of two hostels.( Social Psychiatry and Psychiatric Epidemiology, 27, ) Bellack, A. S., Morrison, R. L., Mueser, K. T. & Wade, J. (1989). Social competence in schizoaffective disorder, bipolar disorder, and negative and non-negative schizophrenia. ( Schizophrenia Research, 2, ) Bruning, J. L. & Kintz, B. L. (1987). Computational handbook of statistics (3rd ed.).(glenview, IL: Scott, Foresman) Cohen, J. (1960). A coefficient of agreement for nominal scales.( Educational and Psychological Measurement, 20, )

14 Page 14 of 16 Doane, J. A., Falloon, I. R. H., Goldstein, M. J. & Mintz, J. (1985). Parental affective style and the treatment of schizophrenia: Predicting course of illness and social functioning.( Archives of General Psychiatry, 42, ) 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, ) Gottman, J. M. (1987). The sequential analysis of family interaction.(in T. Jacob (Ed.), Family interaction and psychopathology: Theories, methods, and findings (pp ). New York: Plenum Press.) Grossman, L. S., Harrow, M., Fudula, J. & Meltzer, H. Y. (1984). The longitudinal course of schizoaffective disorders: A prospective follow-up study.( Journal of Nervous and Mental Disease, 172, ) Grossman, L. S., Harrow, M., Goldberg, J. F. & Fichtner, C. G. (1991). Outcome of schizoaffective disorder at two long-term follow-ups: Comparisons with outcome of schizophrenia and affective disorders.( American Journal of Psychiatry, 148, ) Guy, W. (1976). ECDEU assessment manual for psychopharmacology (Department of Health, Education, and Welfare Publication No. ADM ).(Rockville, MD: National Institute of Mental Health) Hahlweg, K., Goldstein, M. J., Nuechterlein, K. H., Magana, A. B., Mintz, J., Doane, J. A., Miklowitz, D. J. & Snyder, K. S. (1989). Expressed emotion and patient-relative interaction in families of recent-onset schizophrenics.( Journal of Consulting and Clinical Psychology, 57, ) Haley, J. (1963). Strategies of psychotherapy. (New York: Grune & Stratton) Hatfield, A. B., Spaniol, L. & Zipple, A. M. (1987). Expressed emotion: A family perspective. ( Schizophrenia Bulletin, 13, ) Hollingshead, A. & Redlich, F. (1958). Social class and mental illness. (New York: Wiley) Hooley, J. M., Orley, J. & Teasdale, J. D. (1986). Levels of expressed emotion and relapse in depressed patients.( British Journal of Psychiatry, 148, ) Kavanagh, D. J. (1992). Recent developments in expressed emotion in schizophrenia.( British Journal of Psychiatry, 160, ) Lukoff, D., Nuechterlein, K. H. & Ventura, J. (1986). Appendix A: Manual for Expanded Brief Psychiatric Rating Scale (BPRS).( Schizophrenia Bulletin, 12, ) Miklowitz, D. J. (1994). Family risk indicators in schizophrenia.( Schizophrenia Bulletin, 20, ) Miklowitz, D. J., Goldstein, M. J., Doane, J. A., Nuechterlein, K. H., Strachan, A. M., Snyder, K. S. & Magana-Amato, A. (1989). Is expressed emotion an index of a transactional process? I. Parents' affective style.( Family Process, 28, ) 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, ) Miklowitz, D. J., Goldstein, M. J., Nuechterlein, K. H., Snyder, K. S. & Doane, J. A. (1987). The family and the course of recent-onset mania.(in K. Hahlweg & M. J. Goldstein (Eds.), Understanding major mental disorder: The contribution of family interaction research (pp ). New York: Family Process Press.) 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, ) Nuechterlein, K. H. & Dawson, M. E. (1984). A heuristic vulnerability/stress model of schizophrenic episodes.( Schizophrenia Bulletin, 10, ) Nuechterlein, K. H., Dawson, M. E., Gitlin, M., Ventura, J., Goldstein, M. J., Snyder, K. S., Yee, C. M. & Mintz, J. (1992). Developmental processes in schizophrenic disorders: Longitudinal studies of vulnerability and stress.( Schizophrenia Bulletin, 18, )

15 Page 15 of 16 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 (Suppl. 18), ) Overall, J. E. & Gorham, D. R. (1962). The Brief Psychiatric Rating Scale.( Psychological Reports, 10, ) Parker, G. & Hadzi-Pavlovic, D. (1990). Expressed emotion as a predictor of schizophrenia relapse: An analysis of aggregated data.( Psychological Medicine, 20, ) Priebe, S., Wildgrube, C. & Muller-Oerlinghausen, B. (1989). Lithium prophylaxis and expressed emotion.( British Journal of Psychiatry, 154, ) Spitzer, R. L., Endicott, J. & Robins, E. (1978). Research Diagnostic Criteria: Rationale and reliability.( Archives of General Psychiatry, 35, ) Strachan, A. M. (1986). Family intervention for the rehabilitation of schizophrenia: Toward protection and coping.( Schizophrenia Bulletin, 12, ) 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, ) 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, ) Tatsuoka, M. M. (1971). Multivariate analysis: Techniques for educational and psychological research. (New York: Wiley) Vaughn, C. E. & Leff, J. P. (1976). The influence of family and social factors on the course of psychiatric illness: A comparison of schizophrenic and depressed neurotic patients.( British Journal of Psychiatry, 129, ) Wing, J. K., Cooper, J. E. & Sartorius, N. (1974). The measurement and classification of psychiatric symptoms: An instruction manual for the PSE and CATEGO system. (London: Cambridge University Press) Zubin, J. & Spring, B. (1977). Vulnerability A new view of schizophrenia.( Journal of Abnormal Psychology, 86, ) 1 Concern has been expressed that terms like expressed emotion and affective style seem to imply dispositional attributes in relatives that are directly and causally related to patient outcomes ( Hatfield, Spaniol, & Zipple, 1987 ). In fact, several studies suggest that levels of EE and AS in relatives arise in part as reactions to coexistent patient attributes (e.g., Nuechterlein, Snyder, & Mintz, 1992 ) and often change with different phases of the patient's disorder (for a review, see Miklowitz, 1994 ). Furthermore, high-ee attitudes are not limited to family environments and also occur among mental health professionals with whom patients interact ( Ball, Moore, & Kuipers, 1992 ). 2 To determine whether this interaction between diagnosis and AS was due to the effects of one small cell (4 patients in the bipolar high AS cell) and the treatment of AS as a dichotomous variable, a multiple regression model was tested in which diagnosis, total negative AS scores (treated as a continuous variable), and the interaction between diagnosis and AS scores predicted CS response strategy difference scores. BPRS scores again served as covariates. This analysis also indicated a

16 Page 16 of 16 significant Diagnosis AS interaction, standardized B =.74, t (1, 58) = 3.4, p < Despite the unequal cell sizes, the within-group variances in CS difference scores did not differ across the high AS schizophrenia ( n = 28) and the high AS bipolar subgroups ( n = 4), F (3, 27) = 2.2, p >.10. The within-group variances in CS difference scores also did not differ across the low AS schizophrenia ( n = 14) and the low AS bipolar subgroups ( n = 18), F (13, 17) = 1.1, p >.10. Patients' coping style salient response strategy difference scores (raw frequency of self-denigration statements raw frequency of refusal statements) as a function of patient diagnosis and relatives' negative affective style (AS) scores. Positive coping style difference scores indicate that the patient made more self-denigrating than refusal statements; negative scores indicate the reverse. Solid line = schizophrenia group ( n = 42); dashed line = bipolar group ( n = 22).