Relación entre la emoción expresada por el familiar responsable y la conducta sintomática de pacientes con esquizofrenia, incluido el funcionamiento social
- Autores: María Luisa Rascón Gasca, María de Lourdes Gutiérrez López, Marcelo Valencia Collazos, Esther Murow Troice
- Localización: Salud mental, ISSN 0185-3325, Vol. 31, Nº. 3, 2008, págs. 205-212
- Idioma: español
- Títulos paralelos:
- Relationship between expressed emotion of the relative in charge and symptomatic behavior and social functioning of patients with schizophrenia
- Enlaces
- Dialnet Métricas: 3 Citas
-
Resumen
- español
La línea de estudios que contempla los mecanismos familiares estresantes utiliza un concepto denominado Emoción Expresada (EE) en el ambiente familiar, que se refiere a la evaluación de la cantidad y calidad de las actitudes y sentimientos relacionados con la crítica, hostilidad y sobreinvolucramiento que uno de los familiares expresa acerca de uno o varios miembros de la familia diagnosticado con esquizofrenia. Estas actitudes de los familiares se han asociado con la presencia de recaídas en los pacientes a los dos años de haber sido dados de alta, especialmente cuando los miembros de la familia y el paciente conviven en el mismo espacio y pueden tener contacto por lo menos 35 horas o más semanales. Las expresiones emocionales más características comprenden: comentarios críticos, hostilidad, exceso de involucramiento afectivo y aspectos positivos como la calidez, los cuales son percibidos en general como estresantes. La crítica implica intolerancia y desaprobación, el sobreinvolucramiento sugiere intrusividad y control, que incluyen niveles altos de ansiedad en el paciente y que se describen de la siguiente manera:
a) La crítica. Originalmente fue definida como aquellos comentarios o aseveraciones los cuales, por la manera en que son expresados, constituyen comentarios desfavorables sobre la conducta o personalidad del individuo a quién se refiere. Es decir, muestran aversión o desaprobación de la conducta o las características de una persona.
b) El sobreinvolucramiento o sobreprotección. Se presenta más comúnmente en los padres que en algún otro familiar; está compuesta por aspectos de sobreprotección o consentimiento, autosacrificio y malestar emocional, es similar al trato que generalmente se le da a un niño sobreprotegido, con niveles inapropiados de preocupación por parte del familiar. El paciente es visto como menos competente que antes y más vulnerable.
c) La hostilidad. Se presenta cuando existe crítica, por lo que tiene poco valor como predictor independiente. Se considera que está presente cuando el paciente es atacado por lo que es, más que por lo que hace, lo que refleja una dificultad para tolerar y algunas veces para comprender la situación del familiar enfermo.
El propósito de este trabajo consiste en mostrar la relación entre el tipo de Emoción Expresada (EE) (tanto alta como baja) por el familiar responsable (FR), y la Conducta Sintomática (CS), así como con el Funcionamiento Social (FS) del paciente con esquizofrenia. Se plantea también un modelo conceptual para evaluar los factores predictores de la EE alta.
Se utilizó un diseño transversal de una muestra no probabilística y de tipo circunstancial, la selección fue de manera secuencial, los sujetos de estudio fueron 33 familiares responsables de pacientes con esquizofrenia, que asistían a la consulta externa de la Clínica de Esquizofrenia del Instituto Nacional de Psiquiatría Ramón de la Fuente, en la Ciudad de México. Los instrumentos empleados fueron: 1. Cédula de evaluación de la conducta del paciente (SBAS) y 2. Cuestionario–encuesta, evaluación del nivel de Emoción Expresada (CEEE).
Los resultados indicaron que los familiares con EE alta observaron un mayor descuido personal, irritabilidad, violencia y aislamiento por parte del paciente, en tanto que los familiares con EE baja reportaron más miedos o temores, olvidos, dependencia e ideas extrañas como las conductas problemáticas de las personas enfermas. En los familiares con EE baja se observó un mejor funcionamiento en el desempeño de tareas domésticas, en la demostración de afecto, en las actividades realizadas en el tiempo libre, en la conversación y en la demostración de apoyo entre el informante y el paciente.
El modelo de estudio demostró que la mayor presencia de CS y el menor nivel de FS del paciente, fueron variables predictoras de una interacción familiar con características de mayor demostración de crítica, hostilidad y/o sobreinvolucramiento, que explicó 46% de la varianza con niveles de significancia estadística.
- English
In the 1950's, several authors carried out a series of studies focusing on the course of schizophrenia rather than its etiology. They found a link between the living conditions to which patients returned after being discharged from the hospital, and their risk of relapse. A higher risk was observed in those patients that returned to their conjugal or parental home, compared to those who returned to other living conditions. This line of work that explored stressful family mechanisms coined a term known as expressed emotion (EE) —high and low— in the family, which refers to the evaluation of the quantity and quality of attitudes and feelings such as criticism, hostility and over–involvement of a family member towards the person diagnosed with schizophrenia. These attitudes among family members have been associated with the presence of relapse in patients two years after being discharged from the hospital when family members and the patient live in the same household and are in contact 35 hours or more per week.
It has been proved that these attitudes exert an influence, either increasing or decreasing the exacerbation of symptoms and, in some cases, leading to the patient's rehospitalization. Higher rates of relapse (92%) have been found in patients that spend over 35 hours a week with the relative in charge (RIC) and were not taking antipsychotic medication.
It has also been found that when a RIC with high EE is in close contact with the patient, the latter is at risk of experiencing a symptom exacerbation that increases two to four times the probability of relapse.
The most typical emotional expressions are critical comments, hostility, and excessive affective involvement. Criticism and over–involvement are usually perceived as stressful. Criticism implies intolerance and disapproval, whereas over–involvement suggests intrusiveness and control, and includes high levels of anxiety in the patient. Some positive aspects are also found, like the demonstration of warm feelings.
a) Criticism. Includes comments and statements which due to the way that are expressed by the RIC represent unfavorable comments about the behavior or personality of the individual being referred to. In other words, it shows aversion or disapproval of a person's behavior or characteristics.
b)Over–involvement. More commonly found in parents than in other relatives, it includes over–protection or consent, self–sacrifice and emotional distress. The patient is regarded as less competent and more vulnerable.
c) Hostility. Generally occurs when there is criticism, which is why it is of little value as an independent predictor. Hostility occurs when the patient is attacked for what he is, rather than for what he does.
The main objective of this article is to show the relationship between the level of expressed emotion (EE) (high or low) of the relative in charge with symptomatic behavior (SB) and social functioning (SF) of the patient with schizophrenia. It also includes a proposal of a conceptual model to evaluate the predictive factors of high EE.
A transversal non–probabilistic study of 33 relatives of patients with schizophrenia was carried out. The relatives were contacted through the Schizophrenia Clinic in the outpatient unit at the hospital of The National Institute of Psychiatry Ramón de la Fuente in Mexico City.
The instruments used were: 1. The Social Behavior Assessment Schedule (SBAS) and 2. The Questionaire for Measuring the Level of Expressed Emotion (Cuestionario–encuesta, evaluación del nivel de EE [CEEE]).
The results indicated that 14 (42.4%) of the interviewed relatives had high EE and 19 (57.6%) had low EE. The main characteristics associated with high EE in RIC were: living in the same household with the patient's mean age of 54.8 years, having less than 12 years of education, being employed and not having a spouse.
The most frequent expressed emotions were criticism, hostility and over–involvement. In patients, the main characteristics were: being male, young, with a mean age of 29.2 years, single and without employment alternatives, with two or more relapses and with a diagnosis of schizophrenia for five or more years.
The presence of symptoms in the patient's according to relatives with low EE was 31.6% as opposed to 74.1% reported by RIC with high EE.
Relatives with high EE mentioned greater personal neglect, irritability, violent behavior and isolation on the part of the patient, whereas relatives with low EE reported more fears, forgetfulness, dependence and strange ideas as problematic behaviors in the patients. The differences found between relatives with high and low EE regarding the patients' functioning were clearly demonstrated. Relatives with low EE reported better functioning in patients' performance of chores, demonstration of affect, involvement in leisure activities and better communication skills.
Relatives with low EE reported that the persistence of the symptoms in their patients was 31.6%, whereas for those with high EE it was 71.4%.
A logistic regression was used to identify the best predictors of EE, where the dependent variable was the total EE score, and the predictors were the continuous variables for social functioning and symptomatic behavior. A significant association was found between the two variables. Poor social functioning, symptomatic instability in the patient and being the patient's sibling explained 46% of the variance in RIC with high EE. The predictors had high levels of statistical significance.
The model revealed the independent contribution of each variable and its interaction with the others. The level of family EE can be considered as the best predictor of relapse in patients with schizophrenia. Thus, EE acquires a special relevance: when high EE causes relapse, the reduction of the level of EE will lead to a decrease in relapse rates. Although the traditional means of measuring EE through the CFI has been found to be highly effective, it takes a long time to apply and classify the answers of the instrument. Another alternative is the CEEE that has been used in this study, since it has been used in other clinical trials due to the brief time required for training, application and classification of the data.
- español
