Expressed Emotion among Family Caregivers of Persons with Schizophrenia: A Causal Model Study

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Panida Srikhachin
Darawan Thapinta
Hunsa Sethabouppha
Petsunee Thungjaroenkul


              The purpose of this cross-sectional correlational study was to test the Model of Expressed Emotion among Family Caregivers of Persons with Schizophrenia. A hypothesized casual model was developed based on Lazarus and Folkman’s theory of stress and coping, and empirical evidence from a literature review. Relevant factors integrated into the Model included severity of illness, mental health status of the family caregiver, caregiving burden, family functioning, and stigma.  The study participants, recruited by means of purposive sampling, consisted of 385 primary family caregivers of adults with schizophrenia who had been followed up at outpatient units of two major psychiatric hospitals in central Thailand. Data were collected using the Thai Expressed Emotion Scale, the Behavior and Symptom Perception Scale, the Thai General Health Questionnaire-28: the Caregiving Burden Scale, the Chulalongkorn Family Inventory, and the Perceived Stigma Questionnaire. Structural equation modeling was used to test the hypothesized model.
              The study findings revealed that the modified model fitted the data and could explain 57% of variance of expressed emotion. In addition, severity of illness, mental health status, caregiving burden, and family functioning had a direct effect on expressed emotion. Meanwhile, stigma had an indirect effect on expressed emotion, mediated through caregiving burden and mental health status of the family caregiver. The Model can be used as a guideline for developing nursing interventions to reduce caregiving burden, as well as promote mental health status and family functioning among family caregivers of persons with schizophrenia.

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Srikhachin P, Thapinta D, Sethabouppha H, Thungjaroenkul P. Expressed Emotion among Family Caregivers of Persons with Schizophrenia: A Causal Model Study. PRIJNR [Internet]. 2016 Oct. 31 [cited 2022 Dec. 5];20(4):337-49. Available from:
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1. Lieberman JA, Stroup TS, Perkins DO. Essentials of Schizophrenia. Arlington: American Psychiatric Publishing; 2012.

2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington; 2013.

3. Murry CL, Lopez AD. The global burden of disease: a comprehensive assessment of mortality and disability from disease, injuries, and risk factors in 1990 and projected to 2020. Boston: Harvard University Press; 1996.

4. Altamura1 C, Fagiolini A, Galderisi S, Rocca P, Rossi A. Schizophrenia today: epidemiology, diagnosis, course and models of care. J Psychopathol. 2014; 20: 223-243.

5. Department of Mental Health, Ministry of Public Health. Annaual Report 2013. Bangkok: Bangkokblock; 2013.

6. Phanthunane P, Whiteford H, Vos T, Bertram M. Economic burden of schizophrenia: empirical analyses from a survey in Thailand. J Ment Health Policy Econ. 2012; 15(1): 25-32.

7. Lesebikan VO, Ayinde OO. Families burden in caregivers of schizophrenia patients: prevalence and sicio-demographic correlates. Indian J Psychol Med. 2013; 35(1): 60–66.

8. Butzlaff RL, Hooley JM. Expressed emotion and psychiatric relapse: A meta-analysis. Arch Gen Psychiat. 1998; 55(6): 547-552.

9. Hooley JM. Expressed emotion and relapse of psychopathology. Annu Rev Clin Psychol. 2007; 3: 329-352.

10. Brown GW, Monck EM, Carstairs GM, Wing JK. Influence of family life on the course of schizophrenic illness. Brit. J. prev. soc. Med. 1962; 16(55): 55-68.

11. Barrowclough C, Hooly JM. Attibutions and expressed emotion: A review. Clin Psythol Rev. 2003; 23: 849-880.

12. Sunpaweravong J, Weiss SJ, Sutharangsee W, Isaralai S. Expressed Emotion of Family Caregivers of Persons with Schizophrenia: A Study in a Southern Province of Thailand. Thai J Nurs Res. 2007; 11(3): 188-202.

13. Lobban F, Barrowclough C, Jones S. Dose Experessed Emotion need to be understood within a more systemic framework .An examinanation of discrepancies in appraisals between patient diagnosed with schizophrenia and their relatives. Social Psychiatry Psychiatr Epidemiol. 2006; 41(1): 50-55.

14. King S, Ricard N, Rochon V, Steiger H, Nelis S. Determinants of expressed emotion in mothers of schizophrenia patients. Psychiatry Res. 2003; 117: 211–222.

15. Guada J, Brekke JS, Floyd R, Barbour J. The relationships among perceived criticism, family contact, and consumer clinical and psychosocial functioning for African-American consumers with schizophrenia. Community Ment Hlt J. 2009; 45: 106–116.

16. Karanci AN, Inandılar H. Predictors of components of expressed emotion in major caregivers of Turkish patients with schizophrenia. Social Psychiatry Psychiatr Epidemiol. 2002; 37: 80–88.

17. Breitborde NJK, Lo´pez SR, Nuechterlein KH. Expressed Emotion, Human Agency, and Schizophrenia: Toward a New Model for the EE-Relapse Association. Cult Med Psychiatr. 2009; 33: 41–60.

18. Carrà G, Montomoli C, Cazzullo CL, Cleric, M. The association between expressed emotion, illness severity and subjective burden of care in relatives of patients with schizophrenia. Findings from an Italian population. Eur Arch Psychiatry Clin Neurosci. 2012; 12: 1-8.

19. Lazarus RS, Folkman S. Stress, Appraisal and Coping. New York: Springer; 1984

20. Shamsaei F, Cheraghi F, Bashirian S. Burden on family caregivers caring for patients with schizophrenia. Iran J Psychiatry. 2015; 10(4): 239 – 245.

21. Phillips MR, Pearson V, Li E, Xu M, Yang L. Stigma and expressed emotion: a study of people with schizophrenia and their family members in China. Br J Psychiatry. 2002; 181: 488 – 493.

22. Pradyumna SG, Chakrabarti S. Coping among the caregivers of patients with schizophrenia. Ind Psychiatry J. 2015; 24(1): 5 – 11.

23. Moller-Leimkuhler AM, Wiesheu A. Caregiver burden in chronic mental illness: The role of patient and caregiver characteristics. Eur Arch Psychiatry Clin Neurosci. 2012; 262(2): 157-166.

24. Matthieu MM, Ivanoff Á. Using stress, appraisal, and coping theories in clinical practice: assessments of coping strategies after disasters. Brief Treatment and Crisis Intervention. 2006; 6:337–348.

25. Nirmala BP, Vranda MN, Reddy S. Expressed emotion and caregiver burden in patients with schizophrenia. Indian J Psychol Med. 2011; 33(2): 119-122.

26. Kline RB. Principles and Practice of Structural Equation Modeling. New York: The Guilford Press; 2011.

27. Hair JF, Black WC, Babin BJ, Anderson RE, Tatham RT. Multivariate Data Analysis. New Jersey: Pearson Prentice Hall; 2006.

28. Sunpaweravong J. Development of Thai Expressed Emotion Scale (TEES) for family caregivers of schizophrenic patients [Dissertation]. [Songkla]: Graduate studies, Faculty of Nursing Prince of Songkla University; 2006.

29. Pipatananond P., Boontong T., Hanucharurnkul S., Rujkorakarn D., Vorapongsathorn T., Sitthimongkol Y. Caregiver burden predictive model: an empirical test among caregivers for the schizophrenic. Thai J Nurs Res. 2002; 6(2): 24-40.

30. Nilchaikovit T, Sukying C, Silpakit C. Reliability and validity of the Thai version of the General Health Questionaire. Journal of the Psychiatric Association of Thailand. 1996; 41: 2-17.

31. Pipatananond P, Hanucharurnkul S. Development of the Psychiatric Patients’ Caregiver Burden Scale (The PPCBS). Thai J Nurs Res. 2003; 7(1): 37-48.

32. Trangkasombat U. Family functioning in mental illness : a study in Thai families with depressive disorders and schizophrenia. J Fam Psychother. 2008; 19(2): 187–207.

33. Khumhom A. Perceived stigma of caregivers, life skills and perceived stigma of persons with schizophrenia [Master thesis]. [Chiang Mai]: Graduate studies, Faculty of Nursing, Chiang Mai University; 2009.

34. Gómez-de-Regil, Kwapil TR, Barrantes-Vidal N. Predictors of expressed emotion, burden and quality of life in relatives of Mexican patients with psychosis. J Psychiatr Nurs Ment Health Nurs. 2014; 21: 170-179.

35. Yang LH, Phillips MR, Lo G, Chou Y, Zhang X, Hopper K. “Excessive thinking” as explanatory model for schizophrenia: impacts on stigma and “moral” status in Mainland China. Schizophr Bull. 2010; 36(4): 836-845.

36. Chien WT, Chan SWC, Yeung FKK, Chiu HFK, Ng BFL. Perceived stigmatisation of patients with mental illness and its psychosocial correlates: a prospective cohort study. Hong Kong Med J.2015;21(2): 27-31.

37. Carrà G, Montomoli C, Cazzullo CL, Cleric, M. The association between expressed emotion, illness severity and subjective burden of care in relatives of patients with schizophrenia. Findings from an Italian population. Eur Arch Psychiatry Clin Neurosci. 2012; 12: 1-8.

38. Hanzawa S, Bae JK, Tanaka H, Bae YJ, Tanaka G, Inadomi H, et al. Caregiver burden and coping strategies for patients with schizophrenia: Comparison between Japan and Korea. Psychiatry Clin Neurosci. 2010; 64(4): 377-386.

39. Shimodera S, Mino Y, Inoue Y, Izumoto Y, Fujita H, Ujihara H. Expressed emotion and family distress in relatives of patients with schizophrenia in japan. 2000; Compr Psychiatry, 41(5): 392–397.

40. Hsiao CY, Tsai YF. Factors of caregiver burden and family functioning among Taiwanese family caregivers living with schizophrenia. J Clin Nurs. 2015; 24(1112): 15461556.

41. Boger KD, Tompson MC, Pavlis LE, Briggs-Gowan MJ, Carter AS. Parental expressed emotion toward children : prediction family functioning. J Fam Psychol. 2008; 22(5): 784-788.