A 19-year-old man was admitted to an inpatient unit at a local psychiatric hospital with symptoms including somatic and persecutory delusions, command auditory hallucinations, thought disorganization, and thought blocking. He complained of vague pains and blurry vision that he believed were caused by a terminal illness, which he blamed on being “toyed with by a higher power.” He was socially withdrawn and demonstrated a flat affect. He displayed minimal insight into the nature of his symptoms; for example, he made frequent requests to be reevaluated for medical conditions in response to his somatic delusions despite assurances that a thorough evaluation had been done. Further, he denied that his condition could benefit from psychiatric medication. An organic cause of his symptoms was ruled out after an unremarkable physical examination, laboratory tests within normal limits, and a negative urine toxicology screen.
The patient's past clinical history revealed behavioral issues since age 10 years, including being oppositional, defiant, and running away from home. These behaviors led to diagnoses of attention-deficit/hyperactivity disorder and conduct disorder, as well as two previous psychiatric hospitalizations at age 15 and 16 years for behavioral issues. The patient's biological mother had other younger children at home and stated that she could not “manage” the patient, and hence placed him with a foster care agency. His foster mother stated the patient started behaving oddly with numerous somatic complaints, leading to primary care physician and emergency department (ED) visits that were inconclusive. He repeatedly returned to his biological mother's house only to be rejected and turned away. The patient's foster mother also reported being frustrated by his behavior, noting that he “does not listen to anyone.”
The patient first began exhibiting symptoms of psychosis, including auditory hallucinations and somatic delusions, several months prior to his presentation at our inpatient unit. These behaviors were initially attributed to substance use; however, he repeatedly tested negative on urine toxicology screens. Due to negative toxicology screens and lack of affective symptoms, the patient's presentations to the ED for somatic complaints were overlooked and the patient was discharged home. One month prior to his presentation to our unit, the patient decompensated and was briefly hospitalized due to symptoms of thought disorganization, thought blocking, and auditory hallucinations, and was diagnosed with psychosis, not otherwise specified. After his discharge from that hospitalization, he was noncompliant with antipsychotic medication. Immediately prior to his presentation to our inpatient unit, he skipped a follow-up psychiatry appointment to instead see his primary care doctor with somatic complaints and the belief that he had a tumor. After being medically cleared, he returned home; however, he then endorsed suicidal ideation to his foster mother, causing her and the foster agency to contact the emergency medical system. He was taken to an ED and subsequently sent for an inpatient admission at our hospital.
Diagnosis and Treatment
The patient presented with delusions, auditory hallucinations, thought disorganization, thought blocking, and flat affect. The exact duration of the prodrome was unclear; however, the aforementioned symptoms of psychosis began months before his first psychiatric hospitalization. An affective disorder and psychosis induced by a substance or another medical condition were ruled out. The patient was diagnosed with schizophreniform disorder. With further exploration it was clear that the suicidal ideation reported by the patient on admission was due to auditory hallucinations. The patient denied suicidal ideation immediately after admission. Extensive family outreach was done with both biological and foster families during his inpatient stay. He was started on a low dose of risperidone, titrated to 3 mg twice a day, and his thought disorganization, paranoia, and auditory hallucinations improved significantly. He was discharged to an outpatient program.
Duration of untreated psychosis (DUP) is defined as the time from the onset of a patient's first psychotic symptoms to the initiation of treatment with antipsychotic medication.1 The mean values of DUP reported in the literature vary considerably but generally range from 8 to 48 weeks.1 DUP greater than 1 to 3 months is believed to have a significant adverse impact on long-term prognosis, including more severe symptoms at presentation, decreased response to pharmacological treatment, decline in social functioning, and poor quality of life.1–3 The results reported by several early intervention programs suggest that shortening DUP may have a clinically meaningful beneficial impact on long-term outcome.1 Thus, it is critically important to understand the factors that prolong DUP so that they may be effectively targeted by preventive measures and accounted for in the development of treatment plans. The available history suggests that the patient had been experiencing psychotic symptoms for at least several months prior to his first hospitalization for psychosis. Although an accurate diagnosis of psychosis may have been missed during his previous ED visits, we believe that, to a large extent, this case highlights how a contentious family emotional environment may prolong DUP due to caregivers' misunderstanding of the illness and/or by having a detrimental effect on patient insight.
The patient's relationships with his biological family and his foster caregiver represent a potentially important factor in his DUP. These relationships may be explored using the concept of “expressed emotion,” a measure of the family emotional environment in which higher levels of expressed emotion correspond to increased criticism, hostility, and/or emotional overinvolvement expressed by caregivers/relatives toward the patient.4 High expressed emotion has been consistently associated with an increased risk of relapse in schizophrenia; a meta-analysis showed that patients exposed to high expressed emotion had a relapse rate of 65% versus 35% among patients in environments of low expressed emotion,4 and a 2010 Cochrane Review found that family interventions aimed at reducing expressed emotion may reduce the risk of relapse by up to 45% at 12 months and 36% at 24 months compared to standard care.5 A recent study also found that critical comments and emotional overinvolvement by family could have an impact on DUP.6 Therefore, evaluating the family environment of high-risk patients who have never received treatment provides the opportunity to implement intervention strategies that could lead to more favorable outcomes by both reducing expressed emotion and shortening DUP.
Although we did not measure the expressed emotion of this family on a formal scale, through interviews it was concluded that the patient had been often exposed to verbal and nonverbal criticism, hostility, and rejection similar to how they are operationalized in expressed emotion measurement scales.7 The biological mother's placement of the patient in foster care while retaining custody of his siblings resulted in a persistent sense of rejection, and his repeated unsuccessful attempts to reunite with his mother may be perceived by the patient as nonverbal hostility. The foster mother's complaint that the patient was disobedient reflects the criticism domain of expressed emotion. Although this isolated observation is not sufficient to characterize the foster relationship, it has been shown that high expressed emotion during semi-structured interviews with caregivers often reflects their daily interactions with patients.7 If clinicians desire to obtain formal ratings, we suggest the Camberwell Family Inventory, the current gold standard for assessment, or the Five Minute Speech Sample, which is shorter to administer but does not assess hostility/warmth and is less sensitive for detecting high expressed emotion.8
A recent study that examined family-level predictors and correlates of DUP showed that greater family strengths and coping capacity are inversely associated with DUP.9 Likewise, a study investigating the predictors of expressed emotion in first episodes of patients with psychosis found that caregiver criticism is positively correlated with prolonged DUP (Spearman rank order of correlation = 0.4; P < .01).6 There is an attributional model that suggests caregivers' expressed emotion is associated with their beliefs about the illness.10 This model is supported by recent research that found relatives' criticism was predicted by the belief that the patient, rather than the illness, was responsible for their symptoms and behaviors.11 This belief was associated with a lack of understanding about the patient's illness. In the context of these findings it has been proposed that criticism expressed by caregivers may be a maladaptive effort to change the patient's behavior, possibly stemming from their beliefs about the patient and the nature of the illness..6,11 This belief is demonstrated in this patient's history by the perception that his symptoms were due to substance use, despite multiple negative toxicology screens. Thus, critical comments may correlate with longer DUP due to misattributions about patients' culpability for and ability to control their symptoms, leading to delayed recognition that the patient requires specialized treatment to manage them. However, it should be noted that a correlation has been found between criticism and negative symptom severity; thus, caregiver criticism may also be exacerbated by the increased symptom severity associated with longer DUP, suggesting a bidirectional relationship.12
Finally, the patient's insight may also mediate the relationship between expressed emotion and DUP (eg, skipping his psychiatry appointment to see a primary care physician and refusing psychiatric medications). Poor insight is associated with decreased treatment adherence and longer DUP.13 Although poor insight is partly determined by cognitive dysfunction, higher awareness of symptoms in patients may be inversely proportional to parental criticism.14 It was hypothesized that high expressed emotion may cause patients to feel greater shame and thus have less tendency to self-reflect on their illness; this could in turn lead to increased DUP and resistance to treatment.
Prolonged DUP and high caregiver expressed emotion are associated with poor prognosis. In early psychosis, the impact of expressed emotion on outcome may be partially mediated by prolongation of DUP. Family interventions aimed at lowering expressed emotion may reduce relapse and rehospitalization rates (Table 1).15–17 Pairing these methods with early intervention programs that have been shown to reduce DUP may provide even greater benefits, although the effect of early family interventions requires further research.1,5
Strategies Commonly Used in Family Interventions
- Murru A, Carpiniello B. Duration of untreated illness as a key to early intervention in schizophrenia: a review. Neurosci Lett. 2018;669:59–67. doi:. doi:10.1016/j.neulet.2016.10.003 [CrossRef]
- Penttilä M, Jääskeläinen E, Hirvonen N, Isohanni M, Miettunen J. Duration of untreated psychosis as predictor of long-term outcome in schizophrenia: systematic review and meta-analysis. Br J Psychiatry. 2014;205(2):88–94. doi:. doi:10.1192/bjp.bp.113.127753 [CrossRef]
- Schimmelmann BG, Huber CG, Lambert M, Cotton S, McGorry PD, Conus P. Impact of duration of untreated psychosis on pretreatment, baseline, and outcome characteristics in an epidemiological first-episode psychosis cohort. J Psychiatr Res. 2008;42(12):982–990. doi:. doi:10.1016/j.jpsychires.2007.12.001 [CrossRef]
- Butzlaff RL, Hooley JM. Expressed emotion and psychiatric relapse: a meta-analysis. Arch Gen Psychiatry. 1998;55(6):547–552. doi:. doi:10.1001/archpsyc.55.6.547 [CrossRef]
- Pharoah F, Mari JJ, Rathbone J, Wong W. Family intervention for schizophrenia. Cochrane Database Syst Rev. 2010;(12):CD000088. doi:10.1002/14651858.CD000088.pub3 [CrossRef].
- Álvarez-Jiménez M, Gleeson JF, Cotton SM, et al. Differential predictors of critical comments and emotional over-involvement in first-episode psychosis. Psychol Med. 2010;40(1):63–72. doi:. doi:10.1017/S0033291708004765 [CrossRef]
- Amaresha AC, Venkatasubramanian G. Expressed emotion in schizophrenia: an overview. Indian J Psychol Med. 2012;34(1):12–20. doi:. doi:10.4103/0253-7176.96149 [CrossRef]
- Hooley JM, Parker HA. Measuring expressed emotion: an evaluation of the shortcuts. J Fam Psychol. 2006;20(3):386–396. doi:. doi:10.1037/0893-318.104.22.1686 [CrossRef]
- Compton MT, Goulding SM, Gordon TL, Weiss PS, Kaslow NJ. Family-level predictors and correlates of the duration of untreated psychosis in African American first-episode patients. Schizophr Res. 2009;115(2–3):338–345. doi:. doi:10.1016/j.schres.2009.09.029 [CrossRef]
- Barrowclough C, Hooley JM. Attributions and expressed emotion: a review. Clin Psychol Rev. 2003;23(6):849–880. doi:. doi:10.1016/S0272-7358(03)00075-8 [CrossRef]
- Domínguez-Martínez T, Medina-Pradas C, Kwapil TR, Barrantes-Vidal N. Relatives' expressed emotion, distress and attributions in clinical high-risk and recent onset of psychosis. Psychiatry Res. 2017;247(suppl C):323–329. doi:. doi:10.1016/j.psychres.2016.11.048 [CrossRef]
- King S. Is expressed emotion cause or effect in the mothers of schizophrenic young adults?Schizophr Res. 2000;45(1–2):65–78. doi:. doi:10.1016/S0920-9964(99)00174-7 [CrossRef]
- Cuesta MJ, Peralta V, Campos MS, Garcia-Jalon E. Can insight be predicted in first-episode psychosis patients? A longitudinal and hierarchical analysis of predictors in a drug-naïve sample. Schizophr Res. 2011;130(1–3):148–156. doi:. doi:10.1016/j.schres.2011.04.032 [CrossRef]
- MacGregor A, Norton J, Bortolon C, et al. Insight of patients and their parents into schizophrenia: exploring agreement and the influence of parental factors. Psychiatry Res.2015;228(3):879–886. doi:. doi:10.1016/j.psychres.2015.05.005 [CrossRef]
- McFarlane WR. Family interventions for schizophrenia and the psychoses: a review. Fam Process. 2016;55(3):460–482. doi:. doi:10.1111/famp.12235 [CrossRef]
- Pitschel-Walz G, Leucht S, Bäuml J, Kissling W, Engel RR. The effect of family interventions on relapse and rehospitalization in schizophrenia—a meta-analysis. Schizophr Bull. 2001;27(1):73–92. doi:. doi:10.1093/oxfordjournals.schbul.a006861 [CrossRef]
- Leff J. Needs of the families of people with schizophrenia. Adv Psychiatr Treat.1998;4(5):277–284. doi:. doi:10.1192/apt.4.5.277 [CrossRef]
Strategies Commonly Used in Family Interventions
||Description of Strategy
||Educate family and patient about causes of schizophrenia, common symptoms, course and prognosis, role of medication in treatment and prophylaxis, as well as common side effects
||Address and reframe misperceptions regarding the illness and patient behaviors
|Communication skills training
||Emphasize active listening skills and reframing critical comments to more clearly and constructively convey caregivers' concerns
|Enhancement of problem solving and coping Skills
||Reflect on and anticipate problems; break down problems and identify solutions consistent with a low expressed emotion attitude
|Mode of delivery
||Individual versus group sessions: group sessions may be preferable as they allow sharing of experiences and coping strategies, and may have higher retention rates
Multiple-family versus single-family groups: multiple-family groups have shown improved outcomes versus single-family groups, particularly for a patient with a first episode of psychosis
|Duration of intervention
||Longer interventions (>3 months) are superior to brief interventions, and “booster” sessions may be required to maintain beneficial effects of the intervention