The influence of belief: Causal attributions and expressed emotion in schizophrenia, depression, and bipolar disorder

The construct of expressed emotion (EE) is a robust predictor of relapse in schizophrenia and mood disorders. Psychiatric patients who return home from a stay in the hospital are two to three times more likely to relapse if they have relatives who are highly critical, hostile, or emotionally overinvolved. However, much remains to be learned about why some family members develop these high EE attitudes and others do not. The attributional model of EE is based on the notion that there is a link between EE and the beliefs relatives hold about the extent to which patients should be held responsible for their own problems.;The Leeds Attributional Coding System was used to examine the causal beliefs of relatives of patients diagnosed with unipolar depression ( N = 43), bipolar disorder (N = 44), and schizophrenia (N = 45). High EE relatives in all three groups were more likely than were low EE relatives to believe that patients were responsible for their problems, findings that are consistent with the attributional model. This suggests that the link between EE and attributions of responsibility transcends psychiatric diagnosis. The attributional styles of relatives across the three study groups were not identical, however. For example, the spouses of the unipolar depressed patients were more likely to believe that the patients' problems were personal (unique or idiosyncratic) to the patient than were the other two groups of relatives. This finding is consistent with Hooley's (1987) theory that negative symptoms are harder for relatives to accept than are positive symptoms. When depressed patients exhibit negative symptoms, their relatives are more likely to attribute these problems to the patients' themselves (e.g., personality characteristics such as laziness), as opposed to the illness.;The predicted link between the causal beliefs of the relatives and the clinical outcome of the patients was also explored. Although attributions were significantly associated with EE, attributional style did not directly predict 9-month relapse rates for patients in the three diagnostic groups. The causal beliefs of the relatives appear to be more important with respect to understanding EE than they are with respect to predicting relapse.