the family questionnaire: development and validation of a new self-report scale for assessing...

Psychiatry Research 109(2002) 265–279

0165-1781/02/$ - see front matter� 2002 Elsevier Science Ireland Ltd. All rights reserved.PII: S0165-1781Ž02.00023-9

The Family Questionnaire: Development and validation of a newself-report scale for assessing expressed emotion

Georg Wiedemann *, Oliver Rayki , Elias Feinstein , Kurt Hahlwega, a b c

University of Tubingen, Department of Psychiatry and Psychotherapy, Osianderstr. 24, D-72076 Tubingen, Germanya ¨ ¨Max Planck Institute of Psychiatry, Department of Psychiatry, Kraepelinstr. 2-10, D-80804 Munich, Germanyb

Technical University of Braunschweig, Institute of Psychology, Spielmannstr. 12A, D-38106 Braunschweig, Germanyc

Received 14 May 2001; received in revised form 17 January 2002; accepted 27 January 2002

Abstract

The level of expressed emotion(EE) as assessed in the Camberwell Family Interview(CFI) has proved to be oneof the best predictors of relapse in schizophrenia. The present study describes the development and validation of theFamily Questionnaire(FQ), a brief self-report questionnaire measuring the EE status(criticism, emotional over-involvement) of relatives of patients with schizophrenia. The FQ classifications in the initial sample of relatives(Ns76) correlated significantly with the ratings in the CFI subcategories ‘criticism’(78% correct classifications) and‘emotional overinvolvement’(71% correct classifications), as well as with the overall CFI EE ratings(74% correctclassifications). A validation study in an independent second sample(Ns79) yielded similar results. The overallcorrect classification rate of 74% remained unchanged. The FQ had better agreement with the CFI on emotionaloverinvolvement than did other short EE questionnaires.� 2002 Elsevier Science Ireland Ltd. All rights reserved.

Keywords: Expressed emotion; Camberwell Family Interview; Emotional overinvolvement; Schizophrenia; Relatives; FamilyQuestionnaire(FQ)

1. Introduction

Prediction of the risk of relapse in individualswith psychiatric disorders is of great importance,especially with respect to adequate relapse preven-tion. The expressed emotion(EE) concept(Leffand Vaughn, 1985), a measure of attitudes andbehavioral patterns of relatives towards patients,

*Corresponding author. Tel.:q49-7071-298 2297; fax:q49-7071-29 4141.

E-mail address: [email protected](G. Wiedemann).

has been shown to be a good predictor of relapsein patients with various diagnoses, including schiz-ophrenia, eating disorders and mood disorders(Bebbington and Kuipers, 1994; Butzlaff andHooley, 1998).

EE classification of relatives is based mainly ontwo variables ‘criticism’(critical comments, CC)and ‘emotional overinvolvement’(EOI). A thirdvariable, ‘hostility’, is normally associated withhigh levels of CC.

The risk of relapse is three to four-fold greaterfor inpatients with schizophrenia returning to high-

266 G. Wiedemann et al. / Psychiatry Research 109 (2002) 265–279

EE home environments than for those returning tolow-EE families within the first year after dis-charge from the hospital(Kavanagh, 1992).

The semi-structured Camberwell Family Inter-view (CFI, Vaughn and Leff, 1976) is a standard-ized instrument for rating EE. The interview isconducted with each relative individually and takesapproximately 4 h per relative for recording andevaluation, i.e. approximately 8 h per family inthe father–mother–patient constellation. Includingthe approximately 2-week period for rater training,this is a very time-consuming procedure and onethat precludes routine clinical use.

A number of shorter procedures for assessingEE have therefore been developed. In an overviewon the status of EE research, Kavanagh(1992)expressed the view that the development andvalidation of alternatives to the CFI was one ofthe primary tasks confronting future research. Theexisting procedures vary as to whether assessmentof the EE status of relatives is based on questioningof patients, relatives, or both, and whether aninterview or a questionnaire is used.

1.1. Speech sample procedures

In the speech sample procedures, relatives areasked to talk about the patient continuously for 5to 10 min and the speech sample is then analyzed(Gottschalk and Gleser, 1969). There are threesuch procedures: the Gottschalk–Gleser procedure(Gottschalk et al., 1988); the Five Minute SpeechSample(FMSS, Magana et al., 1986); and the 10-˜min ‘short interview’(Wittgen et al., 1989).

1.2. Questionnaires

There are numerous questionnaires: the Per-ceived Criticism Rating(PC, Hooley and Teasdale,1989); the Parental Bonding Instrument(PBI,Parker et al., 1979, 1982); the Level of ExpressedEmotion Scale(LEE, Cole and Kazarian, 1988);the Patient Rejection Scale(PRS, Kreisman et al.,1979); the Family Atmosphere Questionnaire(FEF, a questionnaire in German, Buchkremer andFiedler, 1987; Lewandowski et al., 1989); and theFamily Attitude Scale(FAS, Kavanagh et al.,1997).

For some of the short questionnaires, the corre-lations with the CFI classifications of relatives ofschizophrenic patients have been relatively low(PBI) or contradictory (PBI, PC), whereas forothers they have been somewhat higher(PRS,LEE, FAS). For instance, Kazarian et al.(1990)reported significant correlations between somescales of the LEE and the CFI category CC,although none with the CFI category EOI. For anumber of other questionnaires, no correlations ofEE ratings with CFI EE classifications have beenreported. Therefore, the suitability of these scalesfor determining EE status cannot yet be evaluated.

With the exception of one PBI result(Parker etal., 1989), which has yet to be replicated and wasconfined to the subgroup of mothers, none of thequestionnaire methods achieved high correlationswith the CFI EOI classification. Thus, a question-naire for brief assessment that enables accurateassessment of the EE-relevant categories CCandEOI has yet to be developed.

Our objective in developing the Family Ques-tionnaire (FQ) was to achieve this goal. Ourintention was to provide a brief measure that iseasier to administer and is less time-consumingthan the CFI or the FMSS, but nevertheless is atleast equivalent to the FMSS in terms of validity.It should also be suitable for repeated administra-tion. There should be no need for any trainingbefore it can be used, and the time needed foradministration and evaluation should be minimal.

2. Methods

2.1. Participants

The participants were relatives of inpatients whohad been diagnosed with schizophrenia(for detailssee Section 3.1). The patients had to have beenliving in the same household with their relativesor their partner or spending at least 10 hyweekwith them just before admission to the hospital.The first sample consisted of 76 relatives of 49patients and the second of 79 relatives of 50patients. Sample 1 served for item analysis andreduction of the number of items, and sample 2for validation.

267G. Wiedemann et al. / Psychiatry Research 109 (2002) 265–279

Criteria for social class were measured accord-ing to Kleining (1975) and Kleining and Moore(1968). These classes are very much similar tothose of Hollingshead and Redlich(1958). Socio-logical studies have shown that the structure ofsocial class is very comparable between industrialcountries(Moore and Kleining, 1960). Thus, theclassification of Kleining and Moore is also trans-ferable to the criteria of Hollingshead and Redlich.

2.2. Instruments

2.2.1. Camberwell Family InterviewThe EE status of the relatives was assessed with

the Camberwell Family Interview(CFI, Leff,1976) after the patient had been hospitalized. Tothis end, relevant behavioral patterns and eventsin the life of the patient during the 3 monthspreceding his or her hospitalization were discussedand the feelings and attitudes of the patient’srelatives with regard to these behavioral patternsand events were observed.

The taped interviews were evaluated by tworaters who had completed a 2-week training courserun by one of the main authors of the CFI,Christine Vaughn. Blind reliability assessmentsrevealed that levels of inter-rater agreementbetween the investigators and the criterion rater(C. Vaughn) were 0.88 and above(ns12 tapes)for the distinction between high- and low-EErelatives.

If the relative expressed six or more criticalcomments, he was rated as high EE. The globalindex on the EOI scale ranges from 0 to 5. If therelative was rated 3 or higher on this scale, he wasjudged as high EE.

2.2.2. Family Questionnaire

2.2.2.1. Development of the preliminary version.The first step was to have experienced clinicianslist common statements made by family membersabout a relative with schizophrenia and commonways of behaving with such a relative. In addition,statements were derived from EE-related conceptsor were inspired by existing questionnaires, e.g.the PRS.

The theoretical model of the EE condition wasbased on that developed by Vaughn and Leff(Vaughn and Leff, 1981; Leff and Vaughn, 1985)from qualitative content analyses of CFI interviewsand yielding four characteristic attitudes orresponse styles in relatives:(1) the relative’s levelof intrusiveness; (2) the relative’s emotionalresponse;(3) the relative’s attitude toward theillness; and(4) the relative’s level of toleranceand expectations. The Vaughn and Leff model wassupplemented by considerations of the relationshipbetween high EE and inadequate coping strategies(Falloon et al., 1984; Goldstein et al., 1989).

Based on such descriptive accounts and empir-ical investigations of EE dimensions, items weregenerated for the following areas: ‘intrusiveness’,‘emotional response’, ‘attribution of illness’ and‘coping skills’. Items relating to attitude andbehavior areas recorded in the CFI were alsoincluded(CC, e.g. statements of dislike; EOI, e.g.excessively self-sacrificing). To achieve maximumcorrespondence with CFI categories, a number ofitems reflecting the CFI evaluation criteria(Leffand Vaughn, 1985) were generated for the areasof criticism and emotional overinvolvement.

To minimize inaccurate responses resulting fromthe tendency to ‘social desirability’, the items wereformulated so that they conceptualized negativeresponses not as a fault of the relative, but interms of external attribution as a necessary correc-tive measure or outcome of excessive stress, e.g.‘I have to try not to criticize himyher’. One itemon the PRS appeared to meet these criteria andwas therefore included in the EOI scale. To avoidstereotyped answers with a tendency towards themean, only four possible answers ranging from‘neveryvery rarely’ to ‘very often’ were allowed,with no middle value.

The item pool was submitted to a team of EEexperts, i.e. clinicians who had been trained asCFI raters by C. Vaughn or as FMSS raters by A.Magana, or both. These were experienced clinical˜psychologists and psychiatrists who were familiarwith patients with schizophrenia, their relatives,and the EE literature. All of them had severalyears of experience in clinical work in psychiatrydepartments. All of them had already been engaged


Table 1Parameters in the comparison between the FQ and the CFI

FQ EE CFI EE rating

rating Low High

Low a bHigh c d

Lows‘favorable’ outcome; highs‘unfavorable’ outcome;a,b,c,dsabsolute frequencies;astrue negative;bsfalse neg-ative; csfalse positive; anddstrue positive.

in family work with schizophrenia patients andtheir relatives.

The items were evaluated for breadth of cover-age, ease of understanding and acceptance. Thepreliminary version of the FQ administered to therelatives in sample 1 comprised 130 items.

2.2.2.2. Development of the final version. Thedevelopment of the final 20-item version isdescribed in Section 2.3.

2.3. Statistical analysis

The data were analyzed withSPSSfor Windows,version 6.1.3. The pairwise missing option wasused.

Of the 130 items used in study 1, those 30 itemswere selected that had the highest correlations withCFI CC or CFI EOI. Since the relatives in study2 took part in a variety of investigations, they hadto participate in lengthy interviews and fill outmany questionnaires in addition to the FQ. There-fore, we decided to use this shorter version of theFQ with this sample.

A factor analysis was conducted using theresponses to the pool of 30 items from both studiesbecause the number of participants in the firststudy was too small for a reliable factor analysis.Principal components analysis was used for factorextraction. The scree test was used to determinehow many factors to extract. Both orthogonal(varimax) and oblique(SPSS: oblimin) rotationswere carried out to check for a possible stronginterrelation among the resulting factors. In addi-tion, the optimal factor solution was separatelytested in each sample to evaluate stability.

Sum scores of the final scales were calculated.Reliability (internal consistency) was evaluated bycalculating Cronbach’s alpha for both the com-bined sample and the two samples separately.

In study 1, the cut-off points defining low andhigh EE were determined that yielded the bestagreement with the CFI EE ratings. These cut-offpoints were then applied in study 2. Significantgroup differences were determined by analysis ofvariance. Homogeneity of variance was checkedusing the Levene test.

Provided that predictor and outcome are dichot-omous, as in our case, the prognostic value of thepredictor can be characterized by means of easilyinterpreted parameters. The data on the relationbetween prediction(FQ) and outcome(CFI) canbe entered into a 2=2 table, such as is used inthe x test. This table shows the numbers of hits2

and misses in classification, as well as the trueand false positives and the true and false negatives,i.e. the types of hits and misses(see Table 1 fordefinition and Tables 4, 6, 7 and 9). In addition,we report the contingency coefficient and the phicoefficient.

As the definitions of accuracy, sensitivity, spec-ificity and positive and negative predictive valueare not usually given in the literature, and theseterms are often confused with each other, weprovide the definitions we used(compare Gaebelet al., 1993; Bustillo et al., 1995). The accuracyor overall correct classification rate is calculatedas the proportion of correct predictions:(aqd)y(aqbqcqd). This represents the main parameterfor the quality of the prediction, i.e. it is theprimary test of validity for the FQ. The proportionof correct predictions with regard to high or lowCFI EE ratings is often defined using the para-meterssensitivity wdy(bqd), true positivey(falsenegativeqtrue positive)x and specificity way(aqc), true negativey(true negativeqfalse positive)x.

Some authors(Buchkremer et al., 1991; Holle,1995) consider thepredictive values for the pre-diction of CFI EE ratings to be better suited foruse by clinicians. These values are defined as:ay(aqb) wtrue negativey(true negativeqfalse nega-tive)x, the ‘favorable’ or negative prediction; anddy(cqd) wtrue positivey(false positiveqtrue pos-


itive)x, the ‘unfavorable’ or positive prediction(high CFI EE ratings are looked upon as ‘unfa-vorable’ outcome here). ‘Positive’ and ‘negative’predictive values are used in the sense of clinicalfindings, where a ‘positive’ finding usually meansthat there is something unfavorable for the individ-ual and a ‘negative’ finding that no pathology hasbeen found. These formulas depend on the preva-lence of high vs. low CFI EE ratings in theparticular sample. Therefore, the predictive valuescalculated from one study should be used withcaution in another study, i.e. in another sample ofpatients with possibly a very different distributionof high vs. low EE as assessed with the CFI. Inthe literature, negative predictive values are oftenmistaken for specificity and positive predictivevalues for sensitivity.

When applying the concept of predictive values,an appropriate cut-off point for dichotomizationhas to be found. The above-mentioned parametersvary, depending on the specific value of this cut-off point: The higher the specificity, the lower thesensitivity and vice versa. Accuracy was taken asthe criterion for optimal dichotomization, i.e. wechose the cut-off point yielding the maximumaccuracy.

In addition to analyzing the data using 2=2tables and reporting phi coefficients of the binaryEE judgements, we provide the Pearson correla-tions of the FQ CC scale with the frequency ofCFI CC and of the FQ EOI scale with the non-binary CFI EOI scale.

Analyzing the data from members of the samefamily as if they were independent samples ratherthan correlated represents a methodological prob-lem. This could be important for both the factoranalyses and the EE classifications. Therefore, wecombined samples 1 and 2, and took one randomlyselected informant per family for the initial anal-ysis. The results were then replicated with thesecond informant, who was again randomly select-ed in the case of three informants. The secondsample will inevitably be small for a replicationof the factor analysis, but it allows replication ofthe internal consistency of the FQ and of the CFIclassification.

3. Results

3.1. Sample characteristics

Neither the patients in the two independentsamples nor the relatives differed significantly insociodemographic or clinical characteristics. The99 patients in the combined sample(55 men, 44women) had a mean age of 28 yearswrange: 16–54 years; standard deviation(S.D.): 9.8 yearsx.They had been diagnosed by a psychiatrist ashaving either schizophrenia(including ICD-9295.0–295.3 and 295.6; 83%), or schizophrenia,schizoaffective type, with primarily schizophrenicsymptoms(ICD-9 295.7; 17%) according to ICD-9 (World Health Organization, 1978) and theResearch Diagnostic Criteria(RDC, Spitzer et al.,1978). For 44 of the 99 patients, this was theirfirst episode of schizophrenia; for 36, their secondor third; and for 19, their fourth or more.

Of the 155 relatives, 116 were parents and 39were partners. The mean age of the 47 fathers was56 years(S.D. 8.3 years); of the 69 mothers, 52years(S.D. 7.0 years); and of the 39 partners(20men, 19 women), 39 years(S.D. 11.2 years). Withregard to socioeconomic status, 35 of the relatives(23%) were classified as lower class, 49(32%) asmiddle class, and 71(46%) as upper class.

For 9 of the 155 relatives, there were missingdata in the CFI rating. Of the remaining 146, 58(40%) were classified as low EE and 88(60%)as high EE; 23(16%) were highly critical, 33(23%) emotionally overinvolved, and 32(22%)both highly critical and emotionally overinvolved.

3.2. Demographic correlates of the FQ scale

The FQ scale criticism did not correlate withsex. The analysis of variance(ANOVA) yielded amean of 21.1 for men(range 10–36) and 22.2 forwomen(range 10–39) (Fs0.92,Ps0.34). How-ever, the FQ scale emotional overinvolvement didcorrelate with sex. The ANOVA yielded a meanof 25.7 for men (range 13–37) and 28.1 forwomen(range 18–37) (Fs9.00,Ps0.003). Thus,there is a sex difference in the FQ EOI score.Women scored significantly higher on the EOIscale compared to men, but this difference was


Table 2Results of the factor analysis with 20 items, varimax-rotatedfactor loadings

Item Factor 1 Factor 2number Criticism Emotional

overinvolvement

20 0.850 0.0294 0.806 0.0798 0.786 0.105

12 0.757 0.13318 0.750 0.06414 0.745 0.0656 0.718 0.134

16 0.712 0.0492 0.701 0.175

10 0.641 0.142

13 0.103 0.7273 0.223 0.6865 0.005 0.6757 0.241 0.6441 0.299 0.597

11 y0.038 0.59519 0.241 0.58215 0.343 0.5269 y0.085 0.468

17 y0.276 0.362

also observed in the CFI score EOI. The CFI EOIscale significantly correlated with sex(x s10.5,2

d.f.s1, Ps0.001). Again, many more women(56% of women) were coded high on the EOIscale in comparison to men(29% of men).

This is a pattern that is very common, at leastin Western societies. Men show much less emo-tional involvement in general than women.

The FQ scores did not correlate with otherdemographic characteristics of the sample. ThePearson correlations of age with the FQ CC scaleand the FQ EOI scale were not significant. Theanalysis of variance of the socioeconomic statusand the FQ scores yielded no significant differ-ences(Fs2.53, Ps0.08 for the CC score;Fs0.88,Ps0.42 for the EOI score).

3.3. Test–retest reliability

The interval over which the test was measuredwas 2 weeks. Test–retest correlation coefficientswere Pearson’srs0.84, P-0.001,Ns35 for theCC scale, andrs0.91, P-0.001 for the EOIscale.

3.4. Factor analysis

3.4.1. Factor analysis with 30 itemsThe initial factor analysis with 30 items identi-

fied two factors that together accounted for 43.5%of the variance. The orthogonal and oblique solu-tions were comparable. The interrelation of theoblimin-rotated factors was 0.17.

The first factor accounted for 30.8% of thevariance. It consisted of 14 items, which wereclearly related to the construct criticism(CC). Thesecond factor explained 12.7% of the variance. Itconsisted of 16 items, which could be assigned tothe construct emotional overinvolvement(EOI).The factor EOI appeared to be less homogeneousthan the factor CC. There were more items thathad somewhat higher loadings on the other factor.

Before the second factor analysis, 10 items weredeleted. Four were from the factor CC and hadrelatively high loadings on the factor EOI(‘Thereare things about himyher that annoy me,’ ‘Heysheis a very difficult person,’ ‘I have to criticize himyher,’ and ‘Heyshe takes too much of my time’).

Six were from the factor EOI. Four of these alsohad relatively high loadings on the factor CC(‘Ihave given up a lot for himyher,’ ‘I keep trying tostart a conversation with himyher,’ ‘Basically, heyshe only has emotional problems,’ and ‘I like himyher very much’), and two had low loadings onboth factors(‘I try to influence hisyher behavior,’and ‘I enjoy being with himyher’).

3.4.2. Factor analysis with 20 itemsThe second factor analysis with the remaining

20 items identified two factors that togetheraccounted for 48.7% of the variance. Varimax(Table 2) and oblimin rotation yielded similarresults. The oblique solution resulted in a correla-tion of the two factors of 0.19.

The first factor, CC, explained 33.7% of thevariance; Cronbach’s alpha was 0.92. As in thefactor analysis with 30 items, the CC factor wasvery homogeneous. The second factor, EOI,accounted for 15% of the variance. Although thisfactor was less homogeneous, the resulting Cron-bach’s alpha(0.80) was acceptable.


Table 3FQ criticism scores: differences between relatives with highand low CFI criticism

CFI criticism N FQ criticism scores

Mean S.D. 95% CI

Study 1Low 40 18.9 5.76 17.06–20.74High 28 26.5 5.15 24.54–28.53Total 68 22.0 6.66 20.43–23.66


Table 4Comparison of FQ and CFI criticism classifications

FQ criticism CFI criticism

Study 1 Study 2

Low High Low High

Low 34 9 34 11High 6 19 11 14

Total 40 28 45 25

The items of the factor EOI that had moderateloadings on the factor CC were ‘I thought that Iwould become ill myself’(item 15) and ‘I tend toneglect myself because of himyher’ (item 1). Incontrast, the item ‘Heyshe is an important part ofmy life’ (item 17) had a negative loading on thefactor CC.

Factor analyses for the two subgroups separately(studies 1 and 2) led to similar results. Cronbach’salpha for the factor CC was 0.92 in study 1 and0.91 in study 2, and for the factor EOI, 0.80 instudy 1 and 0.78 in study 2.

The final version of the questionnaire consistsof two scales(‘FQ CC’ and ‘FQ EOI’) with 10items each.(For an English translation of theoriginal German, see Appendix A.)

3.5. Prediction of the CFI EE rating (criterion-related validity) in study 1

We examined the correspondence between theFQ scores and the CFI EE ratings at two levels.First, we looked at whether the specific subtypesof high-EE attitudes(CC and EOI) were reflectedin both instruments. We then examined whether arelative’s EE classification on the FQ was thesame as on the CFI. The same procedure wasapplied in study 2.

3.5.1. Prediction of the CFI CC rating by the FQCC score

For eight of the 76 relatives in study 1, the sumscore for the CC scale could not be calculated

because of missing data on some items. Theremaining 68 relatives had a mean CC score of 22(S.D. 6.7; median 22). Those relatives rated highin CC on the CFI differed significantly in theirFQ CC scores from those rated low(Fs31.5,P-0.001; Table 3).

The cut-off point for the FQ CC scale yieldingmaximum accuracy was a score of 23(lowF23-high). Of the relatives with a high CC score onthe CFI, 68% were correctly predicted by the FQCC scalewdy(bqd), sensitivityx, and of those witha low CC score on the CFI, 85% were correctlypredicted by the FQ CC scaleway(aqc), specific-ityx (Table 4). The accuracy of the FQ CC scalewas 78% overall correct classifications(x s19.8,2

d.f.s1, P-0.001, phis0.54, contingency coeffi-cients0.47).

3.5.2. Prediction of the CFI EOI rating by the FQEOI score

For six of the relatives, the sum score for theEOI scale could not be calculated because ofmissing data on some items. The remaining 70relatives had a mean EOI score of 28(S.D. 4.9;median 28). Those relatives rated high in EOI onthe CFI differed significantly in their FQ EOIscores from those rated low(Fs13.8, P-0.001;Table 5).

The cut-off point yielding maximum accuracywas 27. Of the relatives classified as high EOI onthe CFI, 80% were also classified thus on the FQ.Of the relatives classified as low EOI on the CFI,64% were also classified thus on the FQ(Table6). The overall correct classification rate was 71%(x s13.3, d.f.s1, P-0.001, phis0.44, contin-2

gency coefficients0.40).


Table 5FQ EOI scores: differences between relatives with high andlow CFI EOI

CFI EOI N FQ EOI scores

Mean S.D. 95% CI



Table 6Comparison of FQ and CFI EOI classifications

FQ EOI CFI EOI

Study 1 Study 2

Low High Low High

Low 25 6 33 14High 14 24 7 16

Total 39 30 40 30

Table 7Comparison of FQ and CFI EE classifications

FQ EE CFI EE

Study 1 Study 2

Low High Low High

Low 16 8 23 11High 10 36 7 29

Total 26 44 30 40

3.5.3. Prediction of the CFI EE rating by the FQEE score

When the combined FQ scales were used as ameasure of EE, there was a high degree of agree-ment between the FQ and CFI EE ratings(Table7). On the FQ, participants were rated as high EEif their score on at least one of the two scales wasabove the cut-off point.

Of the relatives who were classified as high EEon the FQ, more than three-quarters were alsoclassified as high EE on the CFI(36 of 46, 78%;unfavorable result; positive predictive value).However, of those who were classified as low onthe FQ, one-third were rated high on the CFI(8of 24, 33%). The overall number of highs andlows did not differ very much between the twomeasures: 46 high-EE and 24 low-EE ratings onthe FQ and 44 high-EE and 26 low-EE ratings onthe CFI.

The FQ correctly identified 36 of 44 relativeswith a high-EE attitude(82%, sensitivity) and 16of 26 relatives with a low-EE attitude(61.5%,specificity) as assessed with the CFI. In addition,it correctly identified 52 of 70 participants(74.3%)with respect to overall CFI ratings of EE(x s2

13.6, d.f.s1, P-0.001, phis0.44, contingencycoefficients0.40).

3.6. Prediction of the CFI EE rating (criterion-related validity) in study 2

3.6.1. Prediction of the CFI CC rating by the FQCC score

For four of the 79 relatives in study 2, the sumscore for the FQ CC scale could not be calculated

because of missing data on several items. The 75remaining relatives had a mean CC score of 21.5(S.D. 6.2; median 21). For five relatives in thisstudy, no CFI rating was available. Those relativeswho were rated high in CC on the CFI differedsignificantly in their FQ CC scores from thoserated low(Fs7.5, Ps0.008; Table 3).

Applying the cut-off point found in study 1yielded the results shown in Table 4. The FQ CCscale correctly classified 14 of 25 relatives(56%)rated high in CC on the CFI and 34 of 45 relatives(75.6%) rated low. The overall correct classifica-tion rate was 68.6%(x s7, d.f.s1, Ps0.008,2

phis0.32, contingency coefficients0.30). Asexpected in a validation study, the figures aresomewhat lower than those in study 1.

3.6.2. Prediction of the CFI EOI rating by the FQEOI score

Here again there were four relatives without FQEOI scores due to missing data. The mean scoreof the remaining 75 was 26.1(S.D. 4.8; median26). Again, for five relatives in this study, no CFIrating was available. Those relatives rated high inEOI on the CFI differed significantly in their FQ


Table 8Results of the factor analysis with the sample with one inform-ant per family, varimax-rotated factor loadings

Item Factor 1 Factor 2number Criticism Emotional

overinvolvement

20 0.846 0.0304 0.830 0.0418 0.811 0.070

18 0.771 0.19612 0.776 0.07914 0.715 0.1126 0.725 0.1162 0.704 0.129

16 0.704 0.20710 0.663 0.170

13 0.256 0.7365 0.345 0.6793 0.041 0.6897 0.291 0.643

11 y0.090 0.6041 0.251 0.540

19 y0.200 0.46515 y0.217 0.2679 0.348 0.565

17 0.334 0.518

EOI scores from those rated low(Fs11.8, Ps0.001; Table 5).

Of the 30 CFI high-EOI relatives, 16(53.3%)were correctly classified with the FQ EOI, and ofthe 40 CFI low-EOI relatives, 33(82.5%) werecorrectly classified(Table 6). Overall, 49 of the70 relatives(70%) were correctly classified withthe FQ EOI scale(x s10, d.f.s1, Ps0.002,2

phis0.38, contingency coefficients0.35).

3.6.3. Prediction of the CFI EE rating by the FQEE score

When the combined FQ scales were used as ameasure of EE as in study 1, 52 of 70 relatives(74.3%) were correctly classified(x s16.6, d.f.s2

1, P-0.001, phis0.49, contingency coefficients0.44; Table 7). Of the 40 high-EE relatives on theCFI, 29(72.5%) were correctly classified with theFQ, and of the 30 low-EE relatives, 23(76.7%)were correctly classified.

Of the 36 relatives who were classified as highEE on the FQ, 29, or more than 80%, received thesame rating on the CFI(unfavorable result; posi-tive predictive value). For the favorable results ornegative predictive value, 23 of 34 classifications(68%) were correct.

3.7. Reanalysis of the combined sample taking thedependency of the observations into account

3.7.1. Replication of the factor analysis

3.7.1.1. Sample with one (sthe first) informantper family. Taking one randomly selected inform-ant per family for the initial analysis of thecombined sample(ssamples 1 and 2; see lastparagraph in Section 2) yielded 95 cases. Thisinitial factor analysis with the combined sampleidentified two factors that together accounted for49.9% of the variance. The orthogonal and obliquesolutions were comparable. The interrelation of theoblimin-rotated factors was 0.19.

The first factor, CC, explained 36.3% of thevariance. It consisted of 10 items, which wereclearly related to the construct criticism.

The second factor explained 13.6% of the vari-ance. It consisted of the other 10 items, whichcould be assigned to the construct emotional over-

involvement. Again, as in the previous analysis,the factor EOI appeared to be less homogeneousthan the factor CC. There were more items thathad somewhat higher loadings on the other factor.

Thus, this factor reanalysis with a sample withindependent observations yielded almost identicalresults compared to the previous factor analysiswith a sample of potentially correlated observa-tions. Table 8 shows the results of this factoranalysis yielding not only two factors again withthe identical items within each factor as in theprevious analysis, but also with almost the sameranking of items within each factor. Within eachfactor, only the succession of two items is inter-changed twice(items 12 and 18, and 16 and 2,within the CC factor; items 3 and 5, and 1 and11, within the EOI factor; compare Tables 2 and8).

3.7.1.2. Sample with the second informant perfamily. Taking the second randomly selectedinformant of the combined sample yielded 43cases. This second factor analysis with the com-


Table 9Comparison of FQ and CFI EE classifications in samples withindependent observations

FQ EE CFI EE

Sample 1 Sample 2

Low High Low High

Low 29 11 10 8High 11 44 6 19

Total 40 55 16 27

Sample 1, sample with one randomly selected informant perfamily; sample 2, sample with the second randomly selectedinformant per family.

bined sample again identified two factors thattogether accounted for 48.1% of the variance.Varimax and oblimin rotation yielded similarresults.

The first factor explained 30.8% of the variance.Again, it consisted of 10 items, which were clearlyrelated to the construct CC.

The second factor accounted for 17.4% of thevariance. The items were related to the constructEOI. Although again this factor was less homo-geneous, the resulting Cronbach’s alpha coefficient(0.82) was acceptable.

Thus, this exploratory factor reanalysis with asmall sample with independent observations yield-ed almost identical results compared to our previ-ous factor analyses with a bigger sample and witha sample of potentially correlated observations.This factor analysis again yielded two factors withthe identical items within each factor as in theprevious analyses. However, the sample size ofthis second sample is too small for an actualreplication of the factor analyses. Therefore, thislast factor analysis is exclusively exploratory.

3.7.2. Replication of the internal consistency ofthe FQ and of the CFI classification

3.7.2.1. Internal consistency. Reliability was eval-uated by calculating Cronbach’s alpha for thesample with one informant and for the samplewith the second informant. The reliability coeffi-cient of the first sample was 0.92 for the CC scaleand 0.79 for the EOI scale, whereas for the secondsample it was 0.90 for CC and 0.82 for EOI.

3.7.2.2. Correspondence between FQ and CFIclassification. We examined whether a relative’sEE classification on the FQ was the same as onthe CFI. The same procedure was applied in bothsamples.

Using the combined FQ scales as a measure ofEE, there was a high degree of agreement betweenthe FQ and CFI EE ratings in the sample with oneinformant (i.e. the first informant): 73 of 95relatives(76.8%) were correctly classified(x s2

26.2, d.f.s1, P-0.001, phis0.53, contingencycoefficients0.46, Table 9). Of the 55 high-EErelatives on the CFI, 44(80%) were correctly

classified with the FQ, and of the 40 low-EErelatives, 29(72.5%) were correctly classified.

In the sample with the second randomly selectedinformant, the FQ correctly identified 19 of 27relatives with a high-EE attitude(70.4%, sensitiv-ity) and 10 of 16 relatives with a low-EE attitude(62.5%, specificity) as assessed with the CFI. Itcorrectly identified 29 of 43 participants(67.5%)with respect to overall CFI ratings of EE(x s2

4.46, d.f.s1, Ps0.035, phis0.32, contingencycoefficients0.31; Table 9).

When we further divided the sample with one,i.e. the first informant, into the two samplescorresponding to our two original studies 1 and 2,34 of 45 relatives(75.5%) were correctly classified(x s10.1, d.f.s1, Ps0.002, phis0.47, contin-2

gency coefficients0.43) in study 1, whereas 39of 50 relatives (78%) were correctly classified(x s15.6, d.f.s1, P-0.001, phis0.56, contin-2

gency coefficients0.49) in study 2.As the sample with the second informant was

comparatively small, we did not subdivide itfurther.

3.8. Non-binary relationship of the FQ to the CFI

In addition to analyzing the data using 2=2tables and reporting phi coefficients, informationabout how well the FQ CC scale correlated withthe frequency of CFI CC is of interest. Thecorrelation was Pearson’srs0.44, P-0.001.Accordingly, the correlation of the FQ EOI scalewith the non-binary CFI EOI scale was Pearson’srs0.42,P-0.001.


4. Discussion

The present study outlines the development andvalidation of the Family Questionnaire(FQ), abrief self-rating scale for assessing the EE statusof relatives of schizophrenic patients. The ques-tionnaire took only minutes to fill in and washighly acceptable to the relatives who were com-pleting it.

Even though the cut-off scores from study 1were used in study 2, the overall correct classifi-cation rate for EE remained unchanged. The ratedid not go down in study 2, as frequently happensin validation studies.

These results were again shown in a reanalysiswith data from members of the same family asindependent samples. The samples from studies 1and 2 were combined and one informant per familywas randomly selected for the first reanalysis, thesecond informant for a replication of this reanalys-is. Both the reanalysis of the factor analyses andthe replication of the internal consistency of theFQ and of the CFI classification revealed consis-tent results with the data from studies 1 and 2.

Thus, this validation can be regarded as beingsuccessful. The FQ seems to be a promising newscale. Furthermore, to the best of our knowledge,the FQ is the only questionnaire so far to haveconsistently yielded significant correlations withCFI EOI.

The overall correct classification rate reportedfor the FMSS is 75%(Magana et al., 1986). In˜Germany, it is 73% in independent studies(Leebet al., 1991; Stark and Buchkremer, 1992). Withour 74% for the FQ in both the original sampleand the validation sample, we have achieved thesame level of accuracy. However, the FMSSrequires more time and effort than the FQ:(1) itis not a self-rating scale, so an interviewer isrequired;(2) the speech sample has to be taped;(3) the tape has to be scored;(4) raters have tobe trained to score the speech sample correctly;(5) raters have to be monitored for reliability; and(6) evaluation time is approximately 30 min fortrained raters. Furthermore, the FMSS requires thatthe relatives be willing to have their speech audio-taped.

Therefore, the FQ is a more cost-effective instru-ment. Thus, it is as good as the FMSS, withapproximately the same overall correct classifica-tion rate, but can be used with a broader range ofparticipants. According to Miklowitz and Gold-stein (1993), short measures of EE are perhapsbest viewed as probes for high-EE attitudes ratherthan as a total substitute for the full CFI.

Because the FMSS underestimates high EE,some authors(e.g. Miklowitz and Goldstein, 1993)have argued that it may not be long enough(orsensitive enough) to capture those high-EE atti-tudes that become apparent only after a certaindegree of rapport has developed between the inter-viewer and the relative. Capturing these attitudesmight not be achievable with a short speechsample, or even with a self-report questionnaire.However, the FQ is much better at identifyinghigh EE than the FMSS(sensitivity 48–65%;Magana et al., 1986; Leeb et al., 1991; Stark and˜Buchkremer, 1992), even though it is shorter andinvolves only a self-rating.

Since the quality of predictions depends on agood balance between sensitivity and specificity,the predictive results presented are more satisfac-tory than those from other brief measures forassessing EE. The FMSS predicts low EE success-fully (high specificity), but does not do well onhigh EE(low sensitivity), whereas the FQ predictshigh and low EE almost equally well(high sensi-tivity and moderate-to-high specificity).

In terms of (unfavorable) positive predictivevalue and(favorable) negative predictive value,the results of all FMSS studies and of this FQstudy are comparable. The positive predictive val-ue of both instruments is approximately 80% andthe negative predictive value approximately 70%(see Table 7 for the FQ).

Although we think that it has been a reasonableway of coping with the problem of workload, sincethe relatives in study 2 only rated the 30 itemsthat had been identified from study 1, this proce-dure might have led to a limitation. Ideally, itcould be argued that the full 130-item set shouldagain have been used for study 2. Sample-specificvariance could result in slightly different sets ofitems from the total of 130 being better correlatesof EE in study 1 and study 2. By restricting the


pool of items used in study 2, the upper limit ofthe criterion validity of the scale may have beenrestricted.

A further small point is that the negative natureof the questions might mean that the FQ is subjectto a negative response bias.

The FQ EOI scale appears to be more hetero-geneous than the FQ CC scale. This was to beexpected, since the EOI construct is more complexand less clearly defined than the CC construct. Itinvolves overconcern, overidentification and over-protectiveness. Either all three, or two, or only oneof these facets may be present in various forms inrelatives with high EOI scores. Hence, the high-scoring population may be diverse. Moreover, theCFI and the FQ, or perhaps any ratings by outsideobservers and self-rating measures, may beaddressing different aspects of EOI. Further clari-fication of the relevant aspects of EOI is thereforeneeded. But despite these caveats, the FQ yieldeda relatively good prediction of CFI EOI with itsEOI scale in both studies 1 and 2.

The main cause of misclassifications may bethe generally poor agreement between self-ratingsof behavior and ratings by outside observers. Withthis in mind, our results are encouraging. More-over, self-ratings need not necessarily explainexactly the same amount of variance of a constructas ratings made by others. The overall misclassi-fication might not be an error, but instead anindication that the FQ measures different aspectsof the EE construct than the CFI.

EE misclassifications of relatives based on ques-tionnaires may not necessarily lead to incorrectratings of the risk of relapse. Rather, a cover-uptendency may be less pronounced with a self-rating method than in a face-to-face interview. Theface-to-face nature of the interview may inhibitrelatives from voicing concern or criticism thatthey would express more freely in their responseson a questionnaire(Docherty et al., 1990). If thisis true, then some relatives’ attitudes may actuallybe reflected more accurately in their responses toa questionnaire than in their interview scores. Ofcourse, the assumption made here must be consid-ered hypothetical.

On the other hand, a significant correspondencebetween FQ EE and CFI EE does not automaticallyimply that the questionnaire also has predictivevalidity in relation to relapse, especially as thepredictive validity of the CFI itself is not perfect.

Hooley and Richters(1991) had raters with notraining in evaluating the CFI assess the EE statusof relatives based on CFI tapes and using a Q-sortmethod. Although the authors reported good agree-ment between the Q-sort rating and the CFI vari-ables CC, hostility and warmth(and to a lesserextent also EOI), the Likert-scale ratings did notpredict risk of relapse.

The results of this study highlight the impor-tance of establishing both the concurrent andpredictive validity of any alternative measure ofEE. Thus, a limitation of the present study is thelack of data concerning the predictive validity ofthe FQ. The cautionary note included by Hooleyand Richters(1991) in their article can also beapplied to the FQ: significant correlates of EE willnot necessarily be good predictors of relapse. Thepredictive validity of any alternative measure hasto be demonstrated rather than assumed. In theabsence of data that demonstrate predictive valid-ity, both clinicians and researchers must be circum-spect about using significant correlates of EE asEE substitutes. As a measure of EE, self-reportsmay even be rather poor, while as a predictor ofrelapse, they may hold considerable promise(Hooley and Teasdale, 1989).

Further studies on the predictive validity ofquestionnaires are therefore needed to clarifywhether the CFI and the brief method given predictthe same or different proportions of relapse vari-ance. In the latter case, a combination of the CFIand a brief method might lead to an increase inpredictive validity, as might a combination of theFQ and another brief method, such as the FMSS.Miklowitz and Goldstein(1993) suggested that agood combination of methods might ultimatelyprovide the best prediction. A combination suchas the CFI during the patient’s hospital stay and ashort questionnaire after discharge might predict arelapse more reliably than either assessment alone:a pattern of stable high EE into the post-dischargeperiod might put a patient at a greater risk for


relapse than an unstable pattern, such as high-to-low, or vice versa.

In summary, the FQ is an instrument for assess-ing EE that had 74% agreement with the CFIclassifications of relatives in both samples 1 and2. Overall, the results provide reasonably goodpreliminary evidence of the construct validity ofthe FQ. The instrument could be a valuableresearch tool, both for easier assessment of EEand for refinement of the construct. Showing thatthe FQ correlates with the CFI represents a goodfirst step. However, the next test for the scale willbe its ability to predict relapse, i.e. to identifypatients at high risk of relapse.

Although further validation studies are needed,in particular with respect to the predictive utilityof the scale in relation to relapse, the findingspresented suggest that the FQ has a clear factorstructure, good internal consistency of subscalesand acceptable relationship to the CamberwellFamily Interview. Thus, it extends the existingliterature on self-report measures of expressedemotion.

Acknowledgments

The authors are grateful to their colleagues atthe Max Planck Institute of Psychiatry, Munich,Dr. M. Dose, Dr. H. Durr, Dr. G Hank, and Dr. U.¨Muller, and thank patients and relatives for their¨help and co-operation. We are also grateful for thecomments of two anonymous reviewers. This studywas supported by the German Ministry of Researchand Technology(BMFT).

Appendix A: Family Questionnaire (FQ)

Name:Date:This questionnaire lists different ways in which

families try to cope with everyday problems. Foreach item please indicate how often you havereacted to the patient in this way. There are noright or wrong responses. It is best to note the firstresponse that comes to mind. Please respond toeach question, and mark only one response perquestion.

Nevery Rarely Often Veryvery oftenrarely

1 I tend to neglect myselfbecause of himyher O O O O

2 I have to keep askinghimyher to do things O O O O

3 I often think about whatis to become of himyher O O O O

4 Heyshe irritates me O O O O5 I keep thinking about the

reasons for hisyherillness O O O O

6 I have to try not to criti-cize himyher O O O O

7 I can’t sleep because ofhimyher O O O O

8 It’s hard for us to agreeon things O O O O

9 When something abouthimyher bothers me, Ikeep it to myself O O O O

10 Heyshe does not appreci-ate what I do for himyher O O O O

11 I regard my own needsas less important O O O O

12 Heyshe sometimes getson my nerves O O O O

13 I’m very worried abouthimyher O O O O

14 Heyshe does some thingsout of spite O O O O

15 I thought I wouldbecome ill myself O O O O

16 When heyshe constantlywants something fromme, it annoys me O O O O

17 Heyshe is an importantpart of my life O O O O

18 I have to insist that heyshe behave differently O O O O

19 I have given up impor-tant things in order to beable to help himyher O O O O

20 I’m often angry withhimyher O O O O

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