Pakistan Journal of Medical Sciences


ISSN 1681-715X





Volume 22

October - December 2006

Number 4


PDF of this Article

Expressed Emotions and
Schizophrenia in Pakistan

Arshad Mahmood1, Saima Niaz2, Usman Rashid3, Haroon Rashid Chaudhry4


Objective: To investigate the differences in expressed emotion among families of patients with schizophrenia and develop an instrument for expressed emotion.

Sample and Setting: A sample of 35 families was selected by using non-probability sampling technique. It was hypothesized that there would be significant difference in expressed emotion among families of patients with schizophrenia and families of normal subjects.

Method: A questionnaire based on Likert Scale technique was used to measure expressed emotion of the families. Those members were selected who have spent at least 35 hours with the patient. Independent t-test was performed to see the difference in their expressed emotion on criticism, hostility, positive remarks, warmth and emotional overinvolvement. Descriptive statistics was used to find out the relationship between demographic variables.

Results: The research finding showed a significant difference in expressed emotion between parents of schizophrenics and parents of normal subjects.

Conclusion: This is the first study on expressed emotions in Pakistani perspective and provides guidelines for future management in schizophrenia.

KEY WORDS: Expressed Emotions, Schizophrenia, Emotional over-involvement, Critical comments, Hostility.

Pak J Med Sci October - December 2006 Vol. 22 No. 4 424-428

1. Arshad Mahmood,
Clinical Psychologist,

2. Saima Niaz
Consultant Psychiatrist,

3. Usman Rashid Chaudhry

4. Haroon Rashid Chaudhry
Executive Director,

1-4: Fountain House Lahore,
Lahore - Pakistan.

Arshad Mahmood
Fountain House 37-Lower Mall,
Lahore – Pakistan.

* Received for Publication: March 2, 2006

* Accepted: May 15, 2006


Expressed emotion has been used as a construct in understanding the interaction between patients and their families. A considerable amount of data from Western cultures1,2 suggests that high expressed emotion can lead to relapse in vulnerable individuals, even when they are on medication. However, the data from other cultures are less solid. The present research was conducted to investigate various components of expressed emotion in the cultural context of Pakistan.

The first research instrument to record the range of feelings and emotions found in ordinary families was the Camberwell Family Interview, developed by Brown.2 This is conducted with the key care takers of the patient, and from it the interviewer tries to create a picture of how things have been in the household in the months leading to the onset of illness.

Vaughn and Leff3 studied 43 patients with schizophrenia and 32 patients with depressive neurosis, and were able to follow up 37 and 30 patients respectively in the two groups. Most of the patients with depression came from marital homes. The relapse rate for the patients from homes that showed high expressed emotion was 50%, compared with 12% for those from with low expressed emotion. The authors used seven or more critical comments and an emotional overinvolvement rating of 4 or 5 to rate expressed emotion as high. They found that the amount of face-to-face contact also reflected the status of expressed emotion. They reported that more than 35 hours of face-to-face contact was the crucial cut-off. Those whose exposure was more than 35 hours had higher relapse rates. When they explored the use of medication they found that high expressed emotion subjects who were not on medication were more likely to relapse (78%) than those who were on medication (25%). They argue that low expressed emotion and regular medication act as additive factors in reducing the risk of relapse.

Levels of expressed emotion in families have also been studied in several developing countries. In a Chandigarh-based World Health Organization’s study4 of first-onset schizophrenia, 104 relatives were interviewed for the purposes of assessing expressed emotion. Of the three centres studied (Chandigarh, Aarhus and London) the Chandigarh sample reported the lowest ratings on all of the following: mean number of critical comments; proportion of relatives showing hostility; positive remarks; mean score on warmth; and level of parental overinvolvement. Compared with the 54% of relatives classified as showing high expressed emotion in the two European centres, the Chandigarh sample had only 23% of relatives classed as showing high expressed emotion. More than a quarter (29%) of the Chandigarh sample showed hostility but low criticism. The authors concluded that the Chandigarh relatives commonly express both high criticism and high warmth at the same time. One-year follow-up suggested that the better outcome in cases of schizophrenia in Chandigarh may be related to the high proportion of relatives with low expressed emotion. In a further report, the authors5 suggest that expression of anger in the form of hostility is relatively unmodified by cultural factors.

Hashemi and Cochrane6 reported in a UK based study on expressed emotion in 60 families (20 British Pakistanis, 20 British Sikhs and 20 matched Whites), all of which included a relative with a diagnosis of schizophrenia. They observed that 80% of the British Pakistani, 45% of the White and 30% of the British Sikh families exhibited high levels of expressed emotional over involvement was significantly higher among the British Pakistani group (55% v. 10% for the British Sikh group). They observed that the modal score for White and Sikh relatives on emotional overinvolvement was 1, whereas for British Pakistanis it was 4. Using the conventional rating criteria the researchers found that White patients with high expressed emotion relatives were significantly more likely to relapse than those from low expressed emotion families, whereas for both Asian groups, high expressed emotion did not predict relapse. However, raising the cut-off of emotional over involvement for Pakistani families led to significantly better prediction of relapse.

Research7 has demonstrated that patients from households with high expressed emotion do not differ in their pathology from those in households with low. It is the relatives who differ markedly in their response to the patients and their illnesses. Of the five scales, critical comments, hostility and emotional overinvol- vement have been shown to be the most predictive of relapse.


Development of Expressed Emotion Questionnaire: The development of expressed emotion questionnaire carried out in two phases.

Phase I: An indigenous questionnaire for expressed emotion was developed through analytical approach of test construction. The questionnaire was constructed using the expressed emotion theory of Brown.2 It consisted of five variable of expressed emotion: criticism, hostility, emotional overinvolvement, positive remarks and warmth.

Phase II: The constructed items were given to 6 judges / experts to assess each item for its relevance and suitability to each factor. Only those items that have 80 percent or more censuses were included in the questionnaire.

Sample: The sample consisted of 35 families of patients with schizophrenia and 35 families of normal subjects with equal representation of male and female participants. The families of patients with schizophrenia were taken from Fountain House Lahore, Punjab Institute of Mental Health Lahore, Mayo Hospital Lahore, Services Hospital Lahore, Sir Ganga Ram Hospital Lahore, Ahbab Hospital Lahore and Jinnah Hospital Lahore. The subjects belonged to various regions of Punjab and Azad Kashmir, Pakistan.

Instruments: The three instruments were used in the study.

Personal History Questionnaire: Personal history questionnaire was devised by the researcher to collect information regarding demographic variables.

Positive and Negative Syndrome Scale (PANSS): PANSS8 was administered to validate the diagnosis of schizophrenia. It is a valid test, consist on 9 sub-tests. Its reliability rages 0.73 to 0.83 for each of the subtest.

Expressed Emotion Questionnaire: An indigenous questionnaire was developed which includes 25 items divided into five variables of expressed emotion described above. The items were scored on Likert scale. The questionnaire was conducted in a Semi Structured Interview with the family.

Data Analysis: The data was analyzed using Statistical Package for the Social Sciences9 (SPSS), version 10.0. T-test was carried out to see the difference between experimental and control groups. Descriptive analysis like mean and standard deviation were carried out for demographic profile of the subjects.


The results indicate (Table-I) that there is a significant difference in expressed emotion score between families of patients with schizophrenia (experimental group) and families of normal subjects (control group). Further analysis showed that the subjects differ in critical comments, hostility, emotional overinvolv- ement, positive remarks and warmth. Table-II indicates highest mean score for emotional over involvement. The scores are significant at 0.05 level of significance.

The descriptive analysis in Table-III shows that for most of the subjects this was the first psychiatric admission (34.28%) and there is 2.85% subject in the category of seven admissions.


The aim of the research was to study the expressed emotion and schizophrenia in Pakistan. A purposive sample (n = 35) of schizophrenic families were collected. The results indicates that there is a significant difference between the scores on expressed emotion of two groups thus leading to rejection of null hypothesis that there is no difference between scores of expressed emotion between two groups. Weisman et al10 found that high expressed emotion families viewed the illness and associated symptoms as residing within the patients’ personal control, more than did low expressed emotion families. Family members who perceived the patient as having control over the symptoms of schizophrenia tended to express greater negative emotions such as anger and annoyance toward the patient than did family members who viewed the symptoms as beyond the patients personal control. During the research it was observed that families of people with schizophrenia believe to some extent that the patient has control over his symptoms which creates a negative attitude of patients in their mind. Muser et al11 found that those schizophrenic patients whose relatives have high expressed emotions had a higher rate of rehospitalization and more symptoms.

The findings of the study need to be understood in the cultural perspective. Kamal12 studied expressed emotion in Egyptian perspective and observed that high expressed emotion was present in 55% of the families of patients with schizophrenia. They reported that Egyptian patients tolerated higher levels of criticism before relapse than have been reported in Western studies. They suggested that these levels were inclusive of benign criticism. A similar observation was reported by Okasha et al,13 who found that criticism is an accepted and acceptable component of interpersonal relations in Egyptian culture and that it might well reflect an element of care. It is also possible that criticism and overinvolvement are intertwined and that warmth might act as a key protective factor. Emotional overinvolvement is seen in the West as pathological because it crosses the boundaries of individuals (i.e. it acts against the individual, egocentric position), whereas in our cultures such an approach may be the norm. The mere presence of high expressed emotion might not predict relapse. There is some evidence that outcome in schizophrenia is better in developing countries especially in our neighborhood India.4

Demographic profiles further indicate that number of admissions were higher among rural subjects. Martyns-Yellow14 studied the burden of schizophrenia on the family in Nigerian perspective. They found that rural families experienced more burdens and are more prone to psychiatric morbidity than urban population. In the present study, about 67 percent of schizophrenic population was from rural areas.

Overall, there is clear evidence of the presence of expressed emotion in families with schizophrenia in Pakistani context. It is now to the clinicians to establish the baseline normative data before accepting these findings and establishing family interventions.


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