| Abstract |
Background: The role of the family in the psychosocial rehabilitation of patients with severe
psychiatric disorders, such as schizophrenia and bipolar disorder, is considered extremely important as
family members are the major source of caregiving. Most of the research on family functioning has
included primarily chronic patients and examined certain aspects of intrafamilial transactions, such as
expressed emotion and family burden. Much less attention has been given to more diverse aspects of
family functioning, focusing on cohesion, flexibility and communication of the members to the
families of people with severe psychiatric disorders, particularly in the early stages of the illness, right
after the onset of the first episode. The study of intrafamilial relationships is especially important in
the early stages of psychiatric illness since it can set the foundation for understanding the interaction
and communication patterns in families of patients. Moreover, although there are plenty of reliable and
valid psychometric tools to assess intrafamilial relationships, very few are translated and adapted to
the Greek population.
Aim: Given the dearth of research on family functioning in patients experiencing their first episode of
psychosis (FEP) and the particularities of Greek families, the primary aim of the present PhD thesis is
to provide a comprehensive assessment of intrafamilial relationships in the early stages of the illness
by examining a variety of aspects of family life and examine possible differences in family
functioning of FEP patients in comparison with chronic patients with psychosis and healthy controls.
More specific aims of this thesis are to describe the socio-demographic and illness-related
characteristics associated with family functioning in psychosis and identify the determinants of
unhealthy family functioning in FEP and chronic patients with psychosis and their families;
furthermore, to examine the interplay of family dynamics, as indexed by cohesion and flexibility, with
caregiver’s expressed emotion, family burden, and psychological distress; finally, to determine
whether dysfunctional family functioning contributes to patient relapse and rehospitalisation during a
two-year follow-up. Given the lack of validated scales to evaluate family dynamics in the Greek
context additional aims of this thesis are to translate and validate two useful psychometric instruments
for assessing family dynamics: a) the Family Adaptability and Cohesion Evaluation Scales IV
(FACES IV), and b) the Family Questionnaire for assessing expressed emotion (FQ).
Methods: A total of 50 FEP and 50 chronic patients recruited from the Inpatient Psychiatric Unit of
the University Hospital of Heraklion, Crete, Greece, and their family caregivers participated in the
study. Family functioning was assessed in terms of cohesion and flexibility (FACES IV), expressed
emotion (FQ), family burden (Family Burden Scale; FBS) and caregivers’ psychological distress
(General Health Questionnaire-28; GHQ-28). Patients’ symptom severity (Brief Psychiatric Rating
Scale; BPRS) and psychosocial functioning (Global Assessment Scale; GAS) were assessed by their
treating psychiatrist within two weeks from the caregivers’ assessment. Multivariate linear regression
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models, structural equation modelling (path analysis), and survival analysis adjusted for confounding
variables were used for the statistical analysis of the data.
Results: 1) Families of FEP patients presented significantly lower levels of cohesion and flexibility,
and thus, experienced higher levels of dysfunction as compared to families of healthy controls. In
addition, they presented higher levels of cohesion and flexibility, compared to families of chronic
patients, suggesting that the family system was more balanced and functional. Caregivers of chronic
patients scored significantly higher in criticism and reported higher burden and psychological distress
than those of FEP patients. A high prevalence of emotional overinvolvement was found both in
families of FEP and chronic patients with psychosis.
2) Both socio-demographic and clinical characteristics were found to be significantly associated with
family functioning in psychosis. The caregivers’ characteristics, i.e., female gender, non-working
status, rural origin, urban residence, low financial status, relation to the patient (i.e. being spouses or
siblings rather than parents), less frequent contact with the patient (i.e. 1-2 times per week compared
to daily contact) and family structure (i.e. one parent families), were among the most significant
determinants of family functioning. Also, patients’ socio-demographic characteristics including older
age, low educational level, rural origin, urban residence, unemployment status, as well as illnessrelated
factors, such as earlier onset of mental illness, higher number of hospitalisations, longer
duration of hospitalisation and clinical diagnosis (i.e. schizophrenia compared to bipolar disorder)
impacted negatively intrafamilial relationships.
3) Increased symptom severity was associated with greater dysfunction in terms of family cohesion
and flexibility, increased caregivers’ expressed emotion levels primarily in the form of emotional
overinvolvement rather than criticism, and psychological distress. Family burden was found to be
significantly affected by both symptom severity and patient’s functioning. No significant interaction
effect of chronicity was observed in the afore-mentioned associations.
4) Path analysis showed that neither family cohesion nor family flexibility exerted significant direct
effects on caregivers’ psychological distress. Instead, the effect of flexibility was mediated by
caregivers’ criticism and family burden indicating an indirect effect on caregivers’ psychological
distress. Therefore, unbalanced levels of flexibility in the family were associated with a highly critical
attitude of caregivers toward the patient, which, in turn, may lead to greater burden and higher levels
of psychological distress for themselves.
5) Unbalanced levels of cohesion and flexibility were not found to be significant risk factors for
relapse in psychosis over a two-year follow-up period. High expressed emotion, as indexed primarily
by increased levels of criticism rather than emotional overinvolvement, was associated with increased
risk of relapse and shorter time to relapse. Similarly, high levels of family burden were related to
shorter time to relapse. Illness chronicity did not moderate the afore-mentioned associations.
Conclusions: The findings of this study indicate that unbalanced levels of cohesion and flexibility,
high criticism and burden appeared to be the outcome of psychosis and not risk factors associated with
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the onset of the illness. Furthermore, emotional over-involvement both in terms of positive (i.e.
concern) and negative behaviours (i.e overprotection) is prevalent in Greek families from the early
stages of the illness. Identifying social and illness-related characteristics, such as patient’s severe
psychopathology and a low psychosocial functioning, on family functioning in patients with psychosis
is important to develop strategies for the rehabilitation or prevention of relapse of the patients from the
early stages of the illness. Understanding the cascade of processes that mediate the impact of family
dysfunction (as indexed by unbalanced flexibility levels) on caregivers’ psychological distress through
caregivers’ behaviours (critical attitude toward the patient) and perceived burden is important in
designing more effective family treatments. The present findings highlight the importance of
caregivers’ criticism and burden of care as targets of family psychoeducational interventions. If
implemented early in the course of the disease, such interventions have the potential to reduce relapse
risk for patients with psychosis.
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