Original Research published: 21 November 2019 doi: 10.3389/fpsyt.2019.00854 Ecological Validity of Expressed Emotion in Early Psychosis Lídia Hinojosa-Marqués 1, Tecelli Domínguez-Martínez 2, Thomas R. Kwapil 3 and Neus Barrantes-Vidal 1,4,5* 1 Departament de Psicologia Clínica i de la Salut, Universitat Autònoma de Barcelona, Barcelona, Spain, 2 Centro de Investigación en Salud Mental Global, Dirección de Investigaciones Epidemiológicas y Psicosociales, Instituto Nacional de Psiquiatría “Ramón de la Fuente Muñiz”, Mexico City, Mexico, 3 Department of Psychology, University of Illinois at Urbana-Champaign, Champaign, IL, United States, 4 Departament de Salut Mental, Sant Pere Claver-Fundació Sanitària, Barcelona, Spain, 5 Centre for Biomedical Research Network on Mental Health (CIBERSAM), Instituto de Salud Carlos III, Barcelona, Spain Expressed emotion (EE) is an aspect of the family environment that influences the course of multiple forms of psychopathology. However, there is limited research about how EE dimensions [i.e., criticism and emotional over-involvement (EOI)] are expressed in real-world settings. The present study used experience sampling methodology to investigate: 1) the criterion and construct validity of daily-life, momentary measures of criticism and EOI, and 2) the construct and ecological validity of psychometric EE-dimensions as assessed with the self-report Family Questionnaire (FQ). A total sample of 55 relatives (34 relatives of Edited by: Neeltje EM Van Haren, at-risk mental state patients and 21 of first-episode psychosis patients) were prompted Erasmus University Rotterdam, randomly six times daily for 1-week to assess their current emotional experiences and Netherlands cognitive appraisals. Relatives also completed the FQ. Momentary criticism and EOI were Reviewed by: Maria Semkovska, significantly associated with the two FQ-EE dimensions respectively, supporting the criterion University of Limerick, validity of real-world assessed EE dimensions. As hypothesized, momentary and FQ-EE Ireland dimensions were associated with decreased positive affect, as well as with appraisals of John RE Fox, Cardiff University, less effective coping in daily life. Only momentary EE dimensions were associated with United Kingdom increased momentary negative affect. Partly in contrast with our hypotheses, momentary *Correspondence: criticism and FQ-criticism were more consistently related to situational stress and burden Neus Barrantes-Vidal neus.barrantes@uab.cat than momentary EOI and FQ-EOI. Finally, neither momentary nor FQ-EE dimensions showed distinct patterns of associations with illness attributions. Findings partly support the Specialty section: construct validity of momentary criticism and EOI as well as the construct and ecological This article was submitted to Psychopathology, validity of the FQ as a sensitive measure of EE dimensions. a section of the journal Keywords: experience sampling, criticism, emotional over-involvement, early psychosis, family environment Frontiers in Psychiatry Received: 15 May 2019 Accepted: 30 October 2019 Published: 21 November 2019 INTRODUCTION Citation: The prognostic value of factors identified in the early stages of psychosis (1–3) has renewed the Hinojosa-Marqués L, interest in environmental stressors as co-participating factors in the risk, onset, expression, and Domínguez-Martínez T, Kwapil TR progression of psychosis (4–7). One of the most significant factors in psychosocial research in and Barrantes-Vidal N (2019) Ecological Validity of Expressed psychosis has been expressed emotion (EE) (8), a measure of the family environment used to Emotion in Early Psychosis. describe relatives’ attitudes toward an ill family member. High-EE attitudes, particularly criticism Front. Psychiatry 10:854. and emotional over-involvement (EOI), have been considered the strongest psychosocial predictor doi: 10.3389/fpsyt.2019.00854 of relapse in schizophrenia (9–11). Frontiers in Psychiatry | www.frontiersin.org 1 November 2019 | Volume 10 | Article 854 Hinojosa-Marqués et al. Daily-Life Expression of Expressed Emotion Although most studies on EE have been carried out in criticism dimension manifest critical attitudes at a behavioral patients with chronic psychotic disorders (12, 13), recent level (47–49) and tend to offer demeaning statements in parent- research has focused on the study of EE in the early stages of patient interactions (50). However, findings supporting the the disorder (14, 15), in order to improve the understanding of construct validity of EOI have been less consistent (50, 51). the early development of high-EE and the problematic associated Some studies indicate that high-EOI relatives make intrusive outcomes. Increasing evidence suggests that relatives of patients (52) or ambiguous statements (53), whereas others report that with first-episode of psychosis (FEP) and at-risk mental state they exhibit high rates of positive and supportive statements in (ARMS) often report high-EE levels (16–19). Moreover, relatives interaction studies (54). These studies offer valuable information of patients with early psychosis often report high levels of burden, of the behavioral correlates of EE in laboratory settings. distress, depression, and anxiety related to high levels of EE (20– However, as these paradigms focus on objectively defined family 24). Specifically, there is converging evidence suggesting that EOI interactional tasks (e.g., interactions lasting 10 min or longer), is more related to distress and burden than criticism (17, 25–28). they are unable to capture how EE components are expressed in Given the large variety of negative outcomes associated with daily life and relate to the wide variety of caregiver’s subjective high-EE, both for relatives and patients, it is crucial to examine states within the natural family environment. the psychological underpinnings of EE in early psychosis without Unlike previous research, the current study employed the bias created by the chronic course of the illness and relatives’ experience sampling methodology (ESM) to examine the daily long-term burden. life expression of EE. ESM provides several benefits compared The attributional model of EE posits that relatives’ beliefs to conventional laboratory or clinic-based assessment paradigms about the causes of the patients’ illness are linked to relatives’ (e.g., 55): 1) it enhances ecological validity because it allows to emotional attitudes toward patients (29). It seems that critical evaluate participants in their daily environment, 2) it captures relatives are more likely to perceive symptoms as controllable participant’s experience in the moment, thus minimizing by patients, even at recent-onset psychosis stages (30, 31). retrospective bias, and 3) allows for an examination of the Consequently, they attempt to reduce the undesired behaviors context in which the experience is occurring. To the best of through critically persuading or coercing the patient. In our knowledge, the only study that has used an ecologically contrast, overinvolved relatives tend to attribute symptoms to valid methodology to examine family interactions reported that external factors that are beyond the patients’ control (32, 33). relatives’ high-EE status did not influence relatives’ affect when However, they may also perceive patients’ symptoms under their relatives were in contact with patients (56). Although this work own control (34) and even can report high levels of guilt and/ provided an ecologically valid insight on EE dynamics, it did not or self-blame attributions (35, 36). This in turn makes them specifically measure the expression of EE dimensions in daily life. more likely to exhibit intrusive and/or self-sacrificing attitudes. Therefore, the general purpose of this study was to test the An alternative explanatory model of EE proposes that high-EE ecological validity of the criticism and EOI dimensions in a attitudes may represent a maladaptive attempt to cope with the sample of relatives of early psychosis patients. To this end, the stress of caring for an impaired ill relative; thus, EE behaviors first aim of the current study was to analyze the criterion validity could be deemed as maladaptive coping strategies used to of momentary criticism and EOI (i.e., as measured with ESM) reduce the perceived stress related to the caregiving role (25, by examining their association with the EE-dimensions of the 37). In fact, relatives of patients with schizophrenia with high EE Family Questionnaire (FQ) (57), a widely used psychometric perceive their ability to cope as less effective and more impaired measure of EE. Regarding this first aim, it was predicted that the than those with low-EE (38). Also, emotion-focused strategies, analogous momentary and psychometric indicators of criticism such as avoidant coping, have been related to high-EE attitudes and EOI would be significantly and more strongly related to each in relatives of FEP patients (22, 37). other than to the other dimension. Few studies have examined EE in early psychosis patients, and The second aim was to examine the construct validity of these have typically relied on retrospective reports. Furthermore, momentary criticism and EOI, as well as the construct and the vast majority of studies have not considered how EE is ecological validity of psychometric EE dimensions by examining displayed within the natural family environment. This is a their associations with emotional, cognitive, and interpersonal limitation given that EE is conceptualized within an interactional behaviors occurring in the flow of daily life. We expected that framework (12, 39, 40). Therefore, it is crucial to examine how momentary and psychometric criticism and EOI would show EE is expressed within the contexts of relatives’ interactions both common and distinctive correlates: with patients and in relation to daily appraisals and caregivers’ subjective states in real-world settings. • Both EE dimensions (momentary and psychometric) were The construct and ecological validity of EE has been expected to be related to increased negative affect and supported by research showing that high-EE relatives tend to decreased positive affect, appraisals of less effective coping, be more critical and intrusive in their direct transactions with and momentary reports of increased situational stress patients than low-EE relatives (41–43). However, most studies and burden. have assessed family interactions as a function of global EE, • Based on the attributional model of EE, different correlates were without considering that criticism and EOI involve different expected for criticism and EOI in relation to illness attributions. underlying appraisals and may be associated with differential Momentary and FQ-criticism were predicted to be associated with patterns of behaviors (44–46). Specifically, relatives high on the attributions of control toward the patient, whereas momentary Frontiers in Psychiatry | www.frontiersin.org 2 November 2019 | Volume 10 | Article 854 Hinojosa-Marqués et al. Daily-Life Expression of Expressed Emotion EOI and FQ-EOI were expected to be related to attributions of consistency (Cronbach’s alpha) of the scores for the subscales in personal control over the disorder in daily life. our sample was good, 0.89 for criticism and 0.86 for EOI. ESM data were collected with personal digital assistants [PDAs; Additionally, we explored whether criticism and EOI, as n = 16 (29%)], digital wristwatch and booklet [n = 25 (45%)], and measured by momentary and psychometric self-reports, showed mobile devices [n = 14 (26%)]. The response rates (percentage of differential associations with negative and positive appraisals completed ESM questionnaires) did not significantly differ among about the self, positive appraisals about the patient, as well as the three methods employed, which were, respectively, 56.4, 75.9, with negative and positive appraisals about patients’ behaviors in and 66.8% (F = 2.69; p = 0.077). Note that numerous studies indicate situations of direct and/or recent contact with the patient. Given that these methods produce comparable data in terms of quantity the paucity of previous research the following hypotheses were and quality (63, 64). Participants were signaled randomly six times exploratory. It was expected that high criticism would be related daily (between 11 a.m. and 22 p.m.) for 1 week to complete brief to negative appraisals about the patient, whereas EOI would questionnaires. When prompted by the signal, the participants had 5 show some associations with positive appraisals of the patient. min to initiate responding. After this time interval or the completion of the questionnaire, the PDA or mobile device became inactive until the next signal. Each questionnaire required 2 min to complete. All MATERIALS AND METHODS ESM items were answered on seven-point scales ranging from “not at all” to “very much,” except for three yes/no items (“Are you with Participants and Procedure he/she right now?,” “Since the last beep, did you have contact with The present study is embedded in a larger longitudinal study carried he/she,” “Right now, I wish he/she was here”). out in three Mental Health Centres in Barcelona (Spain) within the The ESM questionnaire included items that inquired about the Sant Pere Claver-Early Psychosis Program (SPC-EPP) (58). A total following domains: 1) momentary criticism; 2) momentary EOI; 3) of 55 relatives of early psychosis patients (34 from ARMS and 21 affect in the moment; 4) appraisals of effective coping; 5) appraisals from FEP patients), recruited in the SPC-EPP, were included in this about the current situation; 6) appraisals of burden; 7) illness study. An additional six participants were enrolled in the study and attributions; 8) appraisals related to the self; 9) positive appraisals completed the questionnaires but were omitted from the analyses about the patient; and 10) a variety of appraisals that are only due to failing to complete the ESM protocols. prompted if there is direct and/or recent contact with the patient. Relatives were referred to the study by their respective The ESM items inquiring about “appraisals in situations of direct affected family members (i.e., early psychosis patients who were and/or recent contact with the patient” were only administered already participating in the study). Patients were informed of the when relatives endorsed either of the items: “Are you with he/she relatives’ study and asked to name the person to whom they have right now?” or “Since the last beep, did you have contact with he/ a significant/close relationship. After getting the consent of the she.” The rest of the ESM items were always administered. patient, the relative was contacted and was asked to participate The momentary criticism index was created using the following into the study. The recruited relatives were those who had the 4 items: “I feel exhausted by (the patient),” “I feel disappointed by most regular contact and/or the most significant relationship (the patient),” “I feel angry with (the patient),” and “It is difficult with the patient. Relatives were predominantly female (67.3%), to deal with (the patient)” (Cronbach’s α = 0.83). Momentary EOI specifically patients’ mothers (63.6%), with the remaining was assessed with the item “I am worried about (the patient).” caregivers being fathers (25.5%), partners, or siblings (11%). Momentary EE items were developed on the basis of construct Mean age of the relatives was 50.7 years old (SD = 8.96). Most definitions and the items of the FQ (57). Summary indices were relatives lived with the patient (85.5%). Participants completed an also computed for negative affect (NA) (Cronbach’s α = 0.81), average of 28.5 (SD = 11.4) usable ESM questionnaires (67.8%). positive affect (PA) (Cronbach’s α = 0.87), and relatives’ positive Patients had to meet ARMS criteria as assessed by the appraisals about patients’ behaviors in situations of direct and/ Comprehensive Assessment of At-Risk Mental States (CAARMS) or recent contact with the patient (Cronbach’s α = 0.81). Table 1 (59) and/or the Schizophrenia Proneness Instrument Adult- displays the ESM items and indices. Version (SPI-A) (60). FEP patients met DSM-IV-TR criteria (61) for any psychotic disorder or affective disorder with psychotic symptoms as established by the Structured Clinical Interview for Statistical Analysis DSM-IV (SCID-I) (62). All relatives provided written informed Pearson correlations were computed to explore the association consent to participate. The project was developed in accordance of momentary EE constructs (i.e., criticism and EOI) with with the Code of Ethics of the World Medical Association psychometric EE dimensions (FQ) using the Statistical Package (Declaration of Helsinki). Ethical approval for the study was for Social Sciences (SPSS), Version 22.0. The effect size of the obtained from the local ethics committee. correlations was interpreted following Cohen’s (65) guidelines (correlations of 0.10 indicate small effect sizes, 0.30 indicate Measures medium effect sizes, and 0.50 indicate large effect sizes). Relatives completed the FQ (57), a well-established instrument The statistical analyses involving the ESM data were conducted to measure EE. The FQ which consists of two 10-item subscales with Mplus 6 (66) ESM data have a multilevel structure in which (criticism and EOI), with items answered on a four-point scale ESM ratings (level 1 data) are nested within participants (level 2 ranging from “never/very rarely” to “very often.” The internal data). Multilevel or hierarchical linear modeling techniques are Frontiers in Psychiatry | www.frontiersin.org 3 November 2019 | Volume 10 | Article 854 Hinojosa-Marqués et al. Daily-Life Expression of Expressed Emotion TABLE 1 | Relatives’ ESM questionnaire and summary indices. dimensions (level 2 predictors) on ESM domains in daily life Questionnaire Summary indices (level 1 dependent measures). 1. Right now, I feel happy. 2. Right now, I feel sad. Indices are computed as the means RESULTS of the items indicated. 3. Right now, I feel I can cope with things Momentary criticism: 20, 21, 22, Associations Between Momentary well. 4. Right now, it is difficult to concentrate and 24 Negative affect: 2, 7, and 8 Expressed Emotion and Family or make decisions. Questionnaire-Expressed Emotion 5. Right now, I feel relaxed. Positive affect: 1, 5 Dimensions 6. Right now, I feel lonely. Positive appraisals about patients’ Momentary criticism and momentary EOI were significantly behaviors: 31, 32, and 34 7. Right now, I feel irritable. correlated in the present sample (r = 0.59, p = 0.000, LLCI = 0.425, 8. Right now, I feel anxious. ULCI = 0.719). Pearson’s correlations revealed strong associations 9. Right now, I feel hopeful. between momentary criticism and FQ-criticism (r = 0.66, p = 0.000, 10. Right now, I feel guilty. LLCI = 0.452, ULCI = 0.814), as well as between momentary EOI and 11. Right now, I have difficulty controlling FQ-EOI (r = 0.51, p = 0.000, LLCI = 0.305, ULCI = 0.675). Following my thoughts and emotions. 12. Right now, I like what I am doing. Cohen (65), effect sizes were of large magnitude. Significant 13. Right now, I feel tired. associations were also found between momentary criticism and 14. Right now, I don’t feel physically well. FQ-EOI (r = 0.42, p = 0.002, LLCI = 0.175, ULCI = 0.623) as well 15. Right now, I feel supported. as between momentary EOI and FQ-criticism (r = 0.45, p = 0.001, 16. My current situation is positive. LLCI = 0.242, ULCI = 0.640), both medium effect sizes. 17. My current situation is stressful. 18. Right now, I feel happy with he/she. 19. Right now, I am worried about he/she. 20. Right now, I feel exhausted by he/she. Associations Between Momentary 21. Right now, I feel disappointed by he/ Expressed Emotion and Emotional, she. Cognitive, and Interpersonal Experiences 22. Right now, I am angry with he/she. 23. Right now, I feel close to he/she. in Daily Life 24. Right now, it is difficult to deal with Table 2 presents the direct effects of the momentary EE dimensions he/she. on relatives’ daily life experiences. As expected, momentary criticism 25. Right now, I feel that he/she doesn’t and EOI were associated with increased NA and decreased PA in make an effort to be well. daily life. Additionally, both momentary EE dimensions were related 26. Right now, he/she is a burden to me. with decreased appraisals of effective coping in everyday life. 27. Right now, I feel he/she cannot function without me. In terms of appraisals about the current situation, momentary 28. ¿Are you with he/she right now? [If criticism and EOI were associated with a decreased enjoyment YES selected: Q31–Q36/If NO of current activities and perceiving the current situation as selected: Q29] less positive. Momentary criticism was associated with reports 29. Since the last beep, did you have contact with he/she? [If YES selected: that the current situation was stressful, whereas contrary to Q31–36/If NO selected: Q30 and END expectations, momentary EOI was not. In relation to burden, of SURVEY] both momentary EE domains showed significant associations 30. Right now, I wish he/she was here. with increased appraisals of feeling burdened by the patient. 31. Right now, he/she is functioning well. Also, contrary to our hypotheses, no differential associations 32. Right now, he/she is in a good mood. 33. Right now, he/she is being disruptive. emerged for the momentary EE dimensions in relation to illness 34. Right now, it is good to have he/she attributions. Both momentary EE dimensions were significantly around. associated with attributions of patients’ control over the disorder 35. Right now, he/she makes me feel as well as with attributions of relatives’ personal control over the exhausted. disorder in daily life. 36. Right now, he/she is a burden to me. Regarding negative and positive appraisals related to the self, momentary criticism was related to appraisals of feeling less a standard approach for the analysis of ESM data (67, 68). Level supported, whereas momentary EOI was associated with feelings 1 predictors were group-mean centered, level 2 predictors were of being lonely. No associations were found between momentary grand-mean centered, and parameter estimates were calculated EE and appraisals of hope and guilt. In relation to relatives’ using robust standard errors. Two types of multilevel analyses positive appraisals about the patient, momentary criticism, were conducted in the present study. Firstly, a series of multilevel and EOI were associated with expressing decreased feelings of regressions were conducted to test the impact of momentary happiness in relation to the patient and less reports of feeling criticism and EOI (level 1 predictors) on emotional, cognitive, emotionally close to the patient. and interpersonal experiences in daily life. Secondly, multilevel As for relatives’ appraisals in situations of direct and/or recent regressions were performed to explore the impact of FQ-EE contact with the patient, momentary criticism and EOI were Frontiers in Psychiatry | www.frontiersin.org 4 November 2019 | Volume 10 | Article 854 Hinojosa-Marqués et al. Daily-Life Expression of Expressed Emotion TABLE 2 | Direct effects of momentary expressed emotion dimensions on relatives’ daily life experiences. Level 1 criterion Level 1 predictors Momentary criticism P 95% CI Momentary EOI P 95% CI Lower Upper Lower Upper Affect in the moment Negative affect index 0.440 (SE = 0.103) 0.000 0.238 0.642 0.092 (SE = 0.028) 0.001 0.037 0.147 Positive affect index −0.399 (SE = 0.081) 0.000 −0.558 −0.267 −0.150 (SE = 0.030) 0.000 −0.208 −0.091 Appraisals of effective coping Right now, I feel I can cope with things well. −0.173 (SE = 0.056) 0.002 −0.284 -0.063 −0.070 (SE = 0.034) 0.037 −0.136 −0.004 Appraisals about the current situation My current situation is positive. −0.214 (SE = 0.070) 0.002 −0.351 −0.076 −0.073 (SE = 0.030) 0.013 −0.131 −0.015 Right now, I like what I am doing. −0.190 (SE = 0.056) 0.001 −0.300 −0.080 −0.057 (SE = 0.028) 0.044 −0.112 −0.001 My current situation is stressful. 0.366 (SE = 0.062) 0.000 0.245 0.468 0.033 (SE = 0.030) 0.271 −0.026 0.093 Appraisals of burden Right now, he/she is a burden to me. 0.321 (SE = 0.097) 0.001 0.131 0.512 0.112 (SE = 0.039) 0.004 0.036 0.188 Illness attributions Attributions of patients’ control over the disorder Right now, I feel that he/she doesn’t make an 0.473 (SE = 0.102) 0.000 0.273 0.673 0.157 (SE = 0.042) 0.000 0.075 0.238 effort to be well. Attributions of relatives’ control over the disorder Right now, I feel that he/she cannot function 0.167 (SE = 0.070) 0.017 0.030 0.304 0.090 (SE = 0.030) 0.002 0.032 0.149 without me. Appraisals related to the self Positive appraisals Right now, I feel hopeful. −0.077 (SE = 0.050) 0.120 −0.175 0.020 −0.036 (SE = 0.019) 0.062 −0.075 0.002 Right now, I feel supported. −0.157 (SE = 0.063) 0.013 −0.281 −0.034 −0.055 (SE = 0.035) 0.110 −0.123 0.012 Negative appraisals Right now, I feel lonely. 0.211 (SE = 0.151) 0.160 −0.084 0.507 0.063 (SE = 0.028) 0.026 0.008 0.118 Right now, I feel guilty. 0.089 (SE = 0.062) 0.148 −0.032 0.210 0.037 (SE = 0.024) 0.125 −0.010 0.084 Positive appraisals about the patient Right now, I feel happy with he/she. −0.605 (SE = 0.128) 0.000 −0.856 −0.354 −0.183 (SE = 0.051) 0.000 −0.283 −0.082 Right now, I feel close to he/she. −0.324 (SE = 0.094) 0.001 −0.509 −0.139 −0.056 (SE = 0.026) 0.031 −0.107 −0.005 Appraisals in situations of direct and/or recent contact with the patient Negative appraisals about patients’ behaviors Right now, he/she is being disruptive. 0.498 (SE = 0.072) 0.000 0.357 0.639 0.198 (SE = 0.039) 0.000 0.121 0.274 Right now, he/she makes me feel exhausted. 0.462 (SE = 0.082) 0.000 0.301 0.623 0.116 (SE = 0.048) 0.017 0.021 0.211 Right now, he/she is a burden to me. 0.264 (SE = 0.154) 0.085 −0.037 0.566 0.044 (SE = 0.053) 0.407 −0.060 0.148 Positive appraisals about patients’ −0.359 (SE = 0.052) 0.000 −0.461 −0.257 −0.181 (SE = 0.036) 0.000 −0.251 −0.112 behaviors index EE,expressed emotion; EOI,emotional over-involvement; SE,standard error; 95% CI,95% confidence interval. associated with current appraisals of feeling exhausted by the items. Specifically, FQ-criticism was associated with increased patient as well as with perceiving the current patient’s behavior reports of feeling exhausted by the patient, disappointed and as disruptive. There were no associations between momentary angry with the patient, as well as with an increased perception EE and appraisals of burden. Moreover, both momentary EE of difficulties for dealing with the patient. FQ-criticism was dimensions were inversely related to positive appraisals about also related to momentary EOI. On the other hand, FQ-EOI patients’ behaviors when relatives were interacting and/or had was related to momentary EOI that is, to increased reports of recently interacted with the patient. worry about the patient. In addition, FQ-EOI was associated with the momentary criticism index, specifically with feeling exhausted by the patient and perceiving difficulties in dealing Impact of Psychometric Expressed with the patient, but not with feeling disappointed or angry Emotion Dimensions on Emotional, with the patient. Cognitive, and Interpersonal Experiences Although none of two FQ-EE dimensions showed in Daily Life significant relationships with momentary NA, both were FQ criticism and EOI scores were significantly correlated in inversely related to momentary PA. Furthermore, both the present sample (r = 0.72, p = 0.000, LLCI = 0.576, ULCI = dimensions were related to decreased appraisals of effective 0.823). Table 3 presents the direct effects of FQ-EE dimensions coping in daily life. on relatives’ daily life experiences. FQ-criticism was related In terms of situational appraisals, both dimensions were with the momentary criticism index and its four individual associated with perceiving situations as less positive and more Frontiers in Psychiatry | www.frontiersin.org 5 November 2019 | Volume 10 | Article 854 Hinojosa-Marqués et al. Daily-Life Expression of Expressed Emotion TABLE 3 | Direct effects of psychometric expressed emotion dimensions on relatives’ daily life experiences. Level 1 criterion Level 2 predictors FQ-criticism P 95% CI FQ-EOI P 95% CI Lower Upper Lower Upper Momentary EE Momentary criticism-index 0.091 (SE = 0.014) 0.000 0.064 0.118 0.062 (SE = 0.018) 0.001 0.026 0.097 Right now, I feel exhausted by he/she. 0.091 (SE = 0.018) 0.000 0.056 0.126 0.093 (SE = 0.018) 0.000 0.057 0.129 Right now, I feel disappointed by he/she. 0.081 (SE = 0.021) 0.000 0.039 0.122 0.045 (SE = 0.024) 0.065 −0.003 0.093 Right now, I am angry with he/she. 0.048 (SE = 0.014) 0.001 0.020 0.076 0.022 (SE = 0.018) 0.226 −0.013 0.057 Right now, it is difficult to deal with he/she. 0.144 (SE = 0.021) 0.000 0.103 0.186 0.088 (SE = 0.032) 0.006 0.626 1.166 Momentary EOI 0.117 (SE = 0.028) 0.000 0.062 0.172 0.141 (SE = 0.028) 0.000 0.086 0.197 Affect in the moment Negative affect-index 0.043 (SE = 0.025) 0.079 −0.005 0.092 0.045 (SE = 0.025) 0.076 −0.005 0.094 Positive affect-index −0.065 (SE = 0.024) 0.007 −0.112 −0.018 −0.074 (SE = 0.025) 0.003 −0.114 0.025 Appraisals of effective coping Right now, I feel I can cope with things well. −0.075 (SE = 0.017) 0.000 −0.108 −0.043 −0.070 (SE = 0.018) 0.000 −0.105 −0.035 Appraisals about the current situation My current situation is positive. −0.071 (SE = 0.019) 0.000 −0.108 −0.034 −0.083 (SE = 0.022) 0.000 −0.125 −0.040 Right now, I like what I am doing. −0.032 (SE = 0.020) 0.104 −0.070 0.007 −0.038 (SE = 0.020) 0.060 −0.078 0.002 My current situation is stressful. 0.082 (SE = 0.023) 0.000 0.037 0.128 0.065 (SE = 0.030) 0.031 0.006 0.124 Appraisals of burden Right now, he/she is a burden to me. 0.117 (SE = 0.048) 0.015 0.023 0.211 0.090 (SE = 0.048) 0.058 −0.003 0.012 Illness attributions Attributions of patients’ control over the disorder Right now, I feel that he/she doesn’t make an effort 0.091 (SE = 0.024) 0.000 0.044 0.138 0.054 (SE = 0.028) 0.050 0.000 0.108 to be well. Attributions of relatives’ control over the disorder Right now, I feel that he/she cannot function without 0.134 (SE = 0.032) 0.000 0.070 0.198 0.135 (SE = 0.032) 0.000 0.072 0.198 me. Appraisals related to the self Positive appraisals Right now, I feel hopeful. −0.041 (SE = 0.017) 0.017 −0.074 −0.007 −0.046 (SE = 0.019) 0.016 −0.083 −0.008 Right now, I feel supported. −0.049 (SE = 0.030) 0.099 −0.106 0.009 −0.048 (SE = 0.027) 0.074 −0.101 0.005 Negative appraisals Right now, I feel lonely. 0.053 (SE = 0.032) 0.093 −0.009 0.115 0.047 (SE = 0.030) 0.115 −0.011 0.104 Right now, I feel guilty. 0.089 (SE = 0.042) 0.034 0.007 0.171 0.106 (SE = 0.040) 0.008 0.027 0.184 Positive appraisals about the patient Right now, I feel happy with he/she. −0.083 (SE = 0.026) 0.001 −0.134 −0.033 −0.099 (SE = 0.028) 0.000 −0.154 −0.044 Right now, I feel close to he/she. −0.065 (SE = 0.027) 0.016 −0.117 −0.012 −0.044 (SE = 0.027) 0.100 −0.097 0.009 Appraisals in situations of direct and/or recent contact with the patient Negative appraisals about patients’ behaviors Right now, he/she is being disruptive. 0.117 (SE = 0.022) 0.000 0.074 0.160 0.072 (SE = 0.028) 0.010 0.017 0.128 Right now, he/she makes me feel exhausted. 0.088 (SE = 0.025) 0.000 0.039 0.136 0.083 (SE = 0.025) 0.001 0.035 0.132 Right now, he/she is a burden to me. 0.012 (SE = 0.041) 0.764 −0.068 0.093 −0.032 (SE = 0.048) 0.513 −0.126 0.063 Positive appraisals about patients’ behaviors index −0.066 (SE = 0.017) 0.000 −0.099 −0.033 −0.054 (SE = 0.018) 0.002 −0.090 −0.019 FQ, Family Questionnaire; EE, expressed emotion; EOI, emotional over-involvement; SE, standard error; 95% CI,95% confidence interval. stressful. No associations were found with appraisals of enjoyment No differential associations were found in relation to the of current activities. Unlike FQ-EOI, FQ-criticism was associated appraisals in situations of direct and/or recent contact with the with increased momentary reports of feeling burdened by the patient. Both FQ-criticism and FQ-EOI displayed significant patient. Regarding illness attributions, both dimensions were relationships with increased reports of feeling exhausted by associated with attributions of relatives’ personal control over the patient as well as with perceiving the patient’s behavior as the disorder. However, only FQ-criticism was associated with disruptive. No associations were found between EE and burden. increased attributions of patients’ control over the disorder as Moreover, both FQ dimensions were inversely related to positive expected. appraisals about patients’ behaviors. As for negative and positive appraisals related to the self, both dimensions were associated with guilt and diminished hopefulness, but were unassociated with feeling supported or DISCUSSION lonely. Both dimensions were associated with decreased feelings of happiness with the patient. However, only FQ-criticism was To the best of our knowledge, this is the first study to explore how associated with feeling less close to the patient. EE dimensions, as measured by momentary and psychometric Frontiers in Psychiatry | www.frontiersin.org 6 November 2019 | Volume 10 | Article 854 Hinojosa-Marqués et al. Daily-Life Expression of Expressed Emotion self-reports, are expressed in daily life by using ESM in a sample Hooley and Hiller (71) found that relatives of schizophrenia of caregivers of patients with early psychosis. Consistent with our patients with high-EE reported reduced satisfaction about their hypotheses, momentary criticism and FQ-criticism, as well as individual activities compared to low-EE relatives. It is likely momentary EOI and FQ-EOI, displayed significant associations that the momentary nature of ESM allows to capture with higher of a large magnitude, thus providing support for the criterion sensitivity the rewarding capacity of situations encountered in validity of momentary EE dimensions. Furthermore, findings the flow of daily life compared to retrospective inventories. showed that both momentary EE and FQ-EE dimensions were In line with our hypotheses, momentary criticism and significantly and meaningfully associated with real-world FQ-criticism were related to daily appraisals of situational stress experiences pertaining to psychological domains that have and burden. However, momentary EOI and FQ-EOI showed been previously related to EE in retrospective and psychometric discrepancies in their association to burden and stress. FQ-EOI, studies that are critical to the definition of EE from a theoretical but not momentary EOI, was associated with increased appraisals standpoint. Overall, the findings partly support the construct of situational stress, whereas only momentary EOI was related validity of momentary criticism and EOI as well as the construct with increased appraisals of feeling burdened by the patient. and ecological validity of the FQ. Thus, criticism had a clearer association with situational stress The strong association between analogous EE momentary and burden than EOI. Overall, these results seem to be partially and psychometric dimensions supported the criterion validity consistent with previous early psychosis findings indicating of momentary criticism and EOI assessments. However, an association of EE with relatives’ distress and/or burden (20, there were also significant associations between momentary 22, 24) but do not replicate previous early psychosis research criticism and FQ-EOI, as well as between momentary EOI and suggesting that EOI is more strongly related to distress and FQ-criticism—although of a medium, not large, magnitude. burden than criticism (17, 25–27). Hence, momentary criticism and momentary EOI appear Partly in contrast with our hypotheses, a distinct pattern to be relatively non-specific indicators of each respective EE of associations was not observed for momentary and FQ-EE dimension (i.e., criticism and EOI). A detailed examination of dimensions in relation to illness attributions. As expected, the relationship between FQ-EOI and the four individual items momentary criticism and FQ-criticism were associated with comprised in the momentary criticism index partially supported increased attributions of patients’ control over the disorder. the discriminant validity of the FQ-EOI dimension, as FQ-EOI This result agrees with previous findings in early psychosis (30, was associated to feeling exhausted by the patient and perceiving 31) and is consistent with the attributional model of EE (29). difficulties for dealing with the patient, but not with the most However, momentary EOI was also associated with attributions representative appraisals of the momentary criticism index (i.e., of control over the disorder by the patient. This seems to be feeling disappointed and angry with the patient). Overall, our partly incongruent with the attributional model of EE referred findings concur with previous research indicating significant above, which posits a specific relationship between criticism and associations between the EE dimensions (69, 70) which contrasts attributions regarding patients’ ability to control their behaviors. with previous suggestions posing that they are uncorrelated and Notwithstanding, EOI has also been related with attributions of represent independent constructs (44–46). control by the patient in the early stages of psychosis (20). On the Overall, the results regarding the daily life expression of other hand, and in line with previous studies relating EOI with criticism and EOI dimensions partly confirmed our hypotheses. relatives’ self-control attributions (34), both momentary EOI Momentary criticism and EOI were related to increased NA and and FQ-EOI were related to attributions of relatives’ control over decreased PA, consistent with previous work indicating that early the disorder. However, in contrast with our hypotheses, both psychosis relatives often report high levels anxiety and depression momentary criticism and FQ-criticism were also related to self- associated to high levels of EE (20, 24, 26, 27). However, FQ-EE control attributions. It is attractive to speculate that at the early dimensions were only associated to decreased PA in daily life, stages of the disorder, when there is great confusion and still a low suggesting that momentary measure of EE is more sensitive for level of knowledge about the disorder, a great majority of relatives capturing NA experiences. Furthermore, both momentary and still exhibit low-defined illness attributions. Thus, relatives may psychometric EE indicators were related to appraisals of less believe that they can control the disorder by themselves and, at the effective coping in daily life. This finding is in accordance with same time, that patients can have a significant control over their previous results from the schizophrenia literature showing that behavior, which may explain the finding of a lack of differential relatives with high-EE perceive their coping ability as poorer than patterns between illness attributions and EE attitudes. As the those with low-EE (38), and further supports the assumption that disorder progresses, relatives may entrench more defined illness EE could be deemed as a maladaptive coping strategy used in an attributions which, in turn, delineate more specific behavioral attempt to reduce the perceived stress related to the caregiving reactions. Moreover, it is likely that the high-emotional impact of role (25, 37). early psychosis on caregivers leads them to a low understanding Regarding relatives’ appraisals about the situation, results of their own feelings (i.e., diminished emotional clarity). showed that FQ and momentary criticism and EOI were Presumably, low levels of emotional clarity may affect the way associated with reports that the current situation was less positive. they appraise patients’ behaviors thus provoking relatives’ However, unlike FQ-EE dimensions, momentary EE dimensions cognitive ambivalence regarding the control of the disorder. Thus, also displayed associations with expressing decreased enjoyment the attributional model of EE based on schizophrenia samples regarding current activities. Consistent with our results, should be tailored to the developmental specificities of early Frontiers in Psychiatry | www.frontiersin.org 7 November 2019 | Volume 10 | Article 854 Hinojosa-Marqués et al. Daily-Life Expression of Expressed Emotion psychosis (20). This would require integrating the pivotal role Regarding relatives’ appraisals of burden in situations of of emotional factors influencing the psychological experience of direct and/or recent contact with the patient, an interesting relatives in at-risk and onset stages of the disorder. finding emerged thanks to the use of ESM. The item assessing Regarding positive and negative appraisals related to the self, burden was prompted at all assessment points (i.e., independent our results showed that, unlike momentary EE, both FQ-EE of whether relatives were with the patient) and also appeared at dimensions were associated with increased reports of feeling guilt the end of the questionnaire within the interactional items (i.e., in daily life. Previous studies have reported associations between those that relatives only answered if they had direct or recent relatives’ guilt related to the patient’s illness and EOI behaviors contact with the patient since the last beep). Of note, both (35, 36). However, Wasserman et al. (72) also found relatives’ momentary EE dimensions and FQ-criticism, but not FQ-EOI, guilt/self-blame to be associated with high-EE overall status showed associations with burden when this item was asked in and posited that relatives may defend against the experience of the general part of the questionnaire. However, when answering blaming themselves by putting the blame onto the patient in a the same item when in direct or recent contact with the patient, critical manner or by behaving in an emotionally over-involved relatives reported negative appraisals as mentioned (being way to repair their wrongdoing. Furthermore, unlike momentary disruptive, makes me feel exhausted), but not feeling burdened. EE, both FQ-EE dimensions were associated to decreased reports An important difference of this item and the other negative of hopefulness. Hopefulness has not been studied in relation to appraisals is that burden is a direct negative assessment of the EE, although it has been conceived as crucial in the process of person, not of behaviors, which may explain the difference in the coping with a psychiatric disorder in a close family member (73, pattern of responses. This finding underscores the relevance of 74). Finally, only momentary criticism was related to appraisals assessing contextual factors to capture the contextual variability of feeling less supported, whereas momentary EOI was associated of psychological phenomena. with feelings of being lonely. In essence, these appraisals could The following limitations should be acknowledged when be conceived as indicators of perceived social support. Of note, interpreting the results. First, our ESM measure of EOI [ESM recent research has found EE to be related with a decreased item: ‘I am worried about (the patient)’] was necessarily brief perception of social support in schizophrenia relatives (75). and concentrated on an essential element but is likely too narrow. In regard to the association of criticism and EOI with daily Although EOI is characterized by relatives’ over-concern, it is positive appraisals about the ill relative, both momentary and FQ-EE also defined by excessive self-sacrifice, over-identification, and dimensions were related to decreased happiness regarding their extreme over-protective behavior with the patient (76). Thus, relative. Also, both momentary EE domains and FQ-criticism (but our momentary EOI measure was probably not comprehensive not FQ-EOI) were associated with reports of feeling less close to the enough to capture the full range of EOI attitudes. Second, it patient. Given that EOI is characterized by the expression of extreme should be noted that we have examined the impact of momentary emotional closeness with the patient (i.e., overidentification) (76), it EE dimensions on momentary emotional and cognitive is not surprising that FQ-EOI was not related to decreased feelings of correlates to investigate the daily life expression of criticism and closeness. The relationship between momentary EOI and appraisals EOI; nevertheless, given the correlational nature of these data, of decreased closeness might indicate that our measure of EOI, the opposite interpretation is also plausible (e.g., increased NA based on the core element of “worrying” but restricted to it, has not contributing to increased reports of momentary EE). Future been sufficient to capture all the nuances of this construct and/or research should examine whether specific patterns of momentary that the number of daily-life assessments was not extensive enough emotional and cognitive experiences predict the emergence of to capture sufficient variance in such sensitive assessment regarding momentary EE at subsequent assessments using longitudinal the parental bond. designs. Finally, it must be pointed out that the sample size of As for relatives’ appraisals about the ill relative when relatives the present study (n = 55) might be considered relatively small were in direct contact and/or had had recent contact with the given the number of analyses conducted. However, it must be patient, both momentary and FQ-EE dimensions were related taken into consideration that it is a substantial sample size in with decreased positive appraisals about patients’ behaviors as the context of this specific literature. Furthermore, the present well as with increased reports of feeling exhausted by the patient study has a sufficient within-person sample based upon the total and/or with perceiving the patient’s behavior as disruptive in the number of ESM observations. Hox (79) advocates the “50/20 current situation. This is consistent with findings that relatives rule” for assessing multilevel data, suggesting that studies should of schizophrenia patients holding highly critical or emotionally have a minimum of 20 measurements nested within a minimum overinvolved attitudes tend to show lower levels of accepting of 50 participants, which indicates that our study should be behavior (77) and make more negative statements (e.g., criticism, adequately powered to test our ESM hypotheses. statements of disagreement) during face-to-face interactions with The expression of EE dimensions in real time as relatives patients than do low-EE relatives (42, 43, 78). Also, our results navigate their real-life settings remains a largely unexplored area concur with previous studies indicating that criticism is related to of research. This study provided a novel contribution by using “belittling and blaming” statements (53) and/or with statements momentary as well as psychometric measures to examine the of disgust and harshness in parent-patient interactions (50). expression of relatives’ EE in relation to a wide variety of real- However, contrary to our findings, some researchers have found world experiences. Although criticism and EOI, as measured EOI associated with high rates of positive/supportive statements by momentary and psychometric self-reports, were expected to in interaction studies (54). show relatively differential relationships with daily-life appraisals Frontiers in Psychiatry | www.frontiersin.org 8 November 2019 | Volume 10 | Article 854 Hinojosa-Marqués et al. Daily-Life Expression of Expressed Emotion and caregivers’ subjective states in real-world settings, this study (Comitè d’Ètica d’Investigació Clínica (CEIC); number 09-40) only partly supports the construct validity of momentary EE and by the Ethics Committee of the Universitat Autònoma de assessments and the construct and ecological validity of the Barcelona (Comissió d’Ètica en l’Experimentació Animal i FQ dimensions. This “low-specificity” pattern of relationships Humana (CEEAH); number 2679). The participants provided between criticism and EOI with real-world experiences might be their written informed consent to participate in this study. related to a developmental issue. The fact that the patients are at an early risk or onset stage of the illness process may indicate that their relatives hyperactivate both the caregiving behavioral AUTHOR CONTRIBUTIONS system to overprotect the patients, as well as coercive and critical attitudes as an attempt to restore the lost normal behavior and LH-M contributed to study conception, study design, data healthy person; these would, respectively, raise EOI and criticism collection, data analyses, and writing of the manuscript. TD-M attitudes. It is possible that if the illness progresses and becomes contributed to study conception, study design, data collection chronic, relatives may start to display a stronger tendency toward and critically revised the manuscript. TK contributed to study either criticism or EOI depending on a complex number of conception, study design, provided assistance regarding data factors pertaining to both the relative (e.g., illness attributions, analyses and critically revised the manuscript. NB-V was the attachment style) and the patient (e.g., severity, disability). principal investigator, conceived the study and contributed to The present study highlights the utility of ESM for assessing study design and writing of the manuscript. All authors have read how the predictions derived from EE theory play out in the and approved the final manuscript. natural family environment. From a clinical viewpoint, the use of ESM provides a detailed assessment of emotional, cognitive, and behavioral EE components and allows for the critical study of contextual influences such as the caregiver-patient interaction. FUNDING This enhanced comprehension of the expression of EE in the This work is supported by the Spanish Ministerio de Economía y flow of daily life should facilitate the adaptation of models of EE Competitividad (PSI2017-87512-C2-01) and the Comissionat per a derived from chronic forms of the disorder to the specificities Universitats i Recerca of Generalitat de Catalunya (2017SGR1612). of early psychosis as well as the development of targeted and NB-V is supported by the Institució Catalana de Recerca i Estudis personalized interventions, including novel approaches such as Avançats (ICREA) Academia Award and the Centro de Investigación ecological momentary interventions (e.g., 80). Biomédica en Red de Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Barcelona, Spain. DATA AVAILABILITY STATEMENT The datasets generated for this study are available on request to ACKNOWLEDGMENTS the corresponding author. 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