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Expressed Emotion and the Double-Bind: Communication of Specific Emotions in Schizophrenia
Unformatted Document Text:  Page 3 found to be associated with increased severity of schizophrenia symptoms. The EE concept was developed in Britain (see Wearden, Tarrier, Barrowclough, Zastowny, & Rahill, 2000). Many studies used the Camberwell Family Interview (CFI), in which a family is interviewed and videotaped. Later, the videotapes are rated for EE. In Western cultures, high EE often predicts relapse in schizophrenia (Hooley & Gotlib, 2000). A meta-analysis of 24 studies, involving a total of 1321 patients, showed that schizophrenia persons with family members and/or close relatives high in EE are considerably more likely to experience clinical relapse (57%) than persons from low EE families (21%: Bebbington, 1992; Bebbington & Kuipers, 1994). Also, there is evidence that family education programs reducing high EE are effective in preventing or delaying relapse and in lowering the needs for psychotropic drugs. Moreover, such intervention in the early phases of an initial schizophrenic episode, or during an initial prodromal phase, may be effective in preventing later illness (Wahlberg & Wynne, 2001). Diathesis-stress and the double-bind. The factors mediating the relationship between EE and schizophrenia relapse are unclear. On one hand, it is clear that genetic factors produce a risk of schizophrenia, but it is also clear that non-genetic factors in the physical or psychosocial environment play a role in determining whether schizophrenia develops in genetically vulnerable individuals. Gottesman and Shields (1971) proposed a diathesis-stress model for the development of schizophrenia, with a genetically-based diathesis, or biological predisposition, conferring a specific risk of schizophrenia combined with general environmental stressors that are not specific to schizophrenia but rather common to many disorders. In Gottesman and Shields’ model, the environmental stress is nonspecific, that is, not "schizophrenogenic" in its own right. Other models suggest that particular kinds of environmental factors pose specific risks for schizophrenia. Perhaps the best known example is the double-bind (DB) hypothesis advanced by the Palo Alto group in the 1950s, suggesting that intractable paradoxes in the family communication system play specific roles in the etiology of schizophrenia (Bateson, Jackson, Haley & Weakland, 1956). True to the traditional view of schizophrenia as a cognitive disorder, the DB was seen as involving propositional paradoxes. Thus, the DB was defined as a message that asserts something, and asserts something about its own assertion, in such a way that these two assertions are mutually exclusive (Watzlawick, Beavin, & Jackson, 1967, p. 212). Although the DB was seen to involve paradoxical propositional communication, emotional DBs were often cited as examples by Watzlawick et al. (1967; 1969). The EE evidence suggests that the development of schizophrenia may be associated not with problems of logical implication, but rather with problems in emotional expression and communication. Indeed, Hooley and Gotlib (2000) used the diathesis-stress conceptualization to integrate finding relating high EE to relapse and treatment in different psychiatric disorders. This conceptualization suggests that interactions with high-EE individuals are stressful and lead to psychiatric disorders in individuals made vulnerable by their genetic makeup (Hooley & Hiller, 2001). Indeed, schizophrenia patients have been found to recall more stressful and fewer non-stressful memories about high-EE as compared to low-EE parents (Cutting & Docherty, 2000). Also, criticism during family transactions was associated with the emergence of unusual thinking patterns in vulnerable patients (Rosenfarb, Neuchterlein, Goldstein, & Subotnik, 2000).

Authors: Buck, Ross., Sheehan, Megan., Cartwright-Mills, Jacquie., Ray, Ipshita. and Ross, Elliott.
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found to be associated with increased severity of schizophrenia symptoms. The EE
concept was developed in Britain (see Wearden, Tarrier, Barrowclough, Zastowny, &
Rahill, 2000). Many studies used the Camberwell Family Interview (CFI), in which a
family is interviewed and videotaped. Later, the videotapes are rated for EE. In Western
cultures, high EE often predicts relapse in schizophrenia (Hooley & Gotlib, 2000). A
meta-analysis of 24 studies, involving a total of 1321 patients, showed that schizophrenia
persons with family members and/or close relatives high in EE are considerably more
likely to experience clinical relapse (57%) than persons from low EE families (21%:
Bebbington, 1992; Bebbington & Kuipers, 1994). Also, there is evidence that family
education programs reducing high EE are effective in preventing or delaying relapse and
in lowering the needs for psychotropic drugs. Moreover, such intervention in the early
phases of an initial schizophrenic episode, or during an initial prodromal phase, may be
effective in preventing later illness (Wahlberg & Wynne, 2001).
Diathesis-stress and the double-bind. The factors mediating the relationship between
EE and schizophrenia relapse are unclear. On one hand, it is clear that genetic factors
produce a risk of schizophrenia, but it is also clear that non-genetic factors in the physical
or psychosocial environment play a role in determining whether schizophrenia develops
in genetically vulnerable individuals. Gottesman and Shields (1971) proposed a diathesis-
stress model for the development of schizophrenia, with a genetically-based diathesis, or
biological predisposition, conferring a specific risk of schizophrenia combined with
general environmental stressors that are not specific to schizophrenia but rather common
to many disorders. In Gottesman and Shields’ model, the environmental stress is
nonspecific, that is, not "schizophrenogenic" in its own right.
Other models suggest that particular kinds of environmental factors pose specific
risks for schizophrenia. Perhaps the best known example is the double-bind (DB)
hypothesis advanced by the Palo Alto group in the 1950s, suggesting that intractable
paradoxes in the family communication system play specific roles in the etiology of
schizophrenia (Bateson, Jackson, Haley & Weakland, 1956). True to the traditional view
of schizophrenia as a cognitive disorder, the DB was seen as involving propositional
paradoxes. Thus, the DB was defined as a message that asserts something, and asserts
something about its own assertion, in such a way that these two assertions are mutually
exclusive (Watzlawick, Beavin, & Jackson, 1967, p. 212).
Although the DB was seen to involve paradoxical propositional communication,
emotional DBs were often cited as examples by Watzlawick et al. (1967; 1969). The EE
evidence suggests that the development of schizophrenia may be associated not with
problems of logical implication, but rather with problems in emotional expression and
communication. Indeed, Hooley and Gotlib (2000) used the diathesis-stress
conceptualization to integrate finding relating high EE to relapse and treatment in
different psychiatric disorders. This conceptualization suggests that interactions with
high-EE individuals are stressful and lead to psychiatric disorders in individuals made
vulnerable by their genetic makeup (Hooley & Hiller, 2001). Indeed, schizophrenia
patients have been found to recall more stressful and fewer non-stressful memories about
high-EE as compared to low-EE parents (Cutting & Docherty, 2000). Also, criticism
during family transactions was associated with the emergence of unusual thinking
patterns in vulnerable patients (Rosenfarb, Neuchterlein, Goldstein, & Subotnik, 2000).


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