Partners' expressed emotion and the control and management of type 1 diabetes in adults

Adaptation and psychometric assessment of the instrument "Partners of Adults with Type 1 Diabetes Distress Scale" in a Brazilian population

Objectives

To adapt the instrument "Partners of Adults with Type 1 Diabetes Distress Scale" (Partner-DDS) into Brazilian culture, and to evaluate the psychometric characteristics of the adapted version.

Methods

All the cultural adaptation steps of the measure's instruments were followed. The psychometric properties such as reliability (stability by test-retest; internal consistency), and convergent construct validity were performed.

Results

Of all 72 partners, 69.4% were male, mean age: 42.69 ± 14.09 years, mean of marriage duration: 14.74 ± 12.41 years, and mean schooling: 11.81 ± 3.91 years.The internal consistency of the instrument (Cronbach Alpha) was 0.90. The intra-class coefficient (stability) was 0.80 (0.72-0.84). The Spearman coefficient (convergent construct validity) between the Partner-DDS scale and the Anxiety subscale of the Hospital Anxiety and Depression Scale (HADS-A) was 0.4273 (p < 0.0002).

Conclusions

The steps of the instruments' cultural adaptation were appropriately performed. The Brazilian version of the Partner- DDS scale demonstrates reliable psychometric properties for being used in POPWT1D distress evaluation in Brazil.

Innovation

The cultural adaptation of Partner-DDS scale into Brazilian Portuguese is a helpful innovation to assess the emotional burden in POPWT1D. This tool could be used to provide education and psychological support for this population.

Affective temperament traits may explain high expressed emotion in caregivers of patients with Alzheimer's disease

BACKGROUND

The negative interactions between Alzheimer's disease (AD) patients and their caregivers may provoke criticism, hostility, and emotional overinvolvement that characterise highly expressed emotion (EE) attitudes. In this study, we hypothesised that affective temperament traits of AD caregivers are related to their high EE levels independent from other patient and caregiver characteristics.

METHODS

Eighty AD patients were assessed through Clinical Dementia Rating Scale (CDR), and Mini-Mental State Examination. Expressed Emotion Scale (EES), Temperament Evaluation of Memphis, Pisa, Paris and San Diego auto-questionnaire, and Hamilton Depression Rating Scale were applied to the caregivers. The high (n = 41) and low EE caregivers (n = 39) were compared with respect to some sociodemographic and clinical characteristics of the patients and caregivers, and affective temperament traits of caregivers. The associations of caregiver EES scores with multiple variables related to patients and caregivers were examined by Pearson correlation tests. We performed multiple linear regression analysis to determine the possible predictors of total EES scores.

RESULTS

High EE caregivers had significantly higher depressive, cyclothymic, and anxious temperament traits than in low EE subjects. A weak positive correlation was found between the total EES scores and Personal Care scores of CDR. Home and hobbies subscale scores of CDR had a moderately significant positive correlation with total EES scores. There was also moderate significant positive correlations between total EE scores and depressive, cyclothymic, anxious, and irritable temperament traits. Linear regression analysis indicated that depressive temperament significantly predicted the high levels of caregiver EE.

CONCLUSION

These findings suggest that caregivers' depressive temperament is predominantly related to their EE levels even after controlling for the severity of AD, and lower educational level of caregivers. Our results may provide evidence that high EE might be a reflection of caregivers' depressive temperament traits, in accordance with the trait hypothesis.

Symptoms, course of Illness, and comorbidity as predictors of expressed emotion in bipolar disorder

High levels of expressed emotions (EE) reflect the amount of criticism and/or over-involvement in families and has been linked to relapse risk in various psychiatric disorders including bipolar disorder (BD). Less clear is which factors contribute to the development and/or maintenance of EE. Therefore, we tested whether patient characteristics, specifically clinical features and personality disorder traits in BD predicted key aspects of EE as assessed by patients and their relatives. Patients with remitted BD and their relatives were asked to complete the Family Attitude Scale (FAS) and the Perceived Criticism Measure (PCM). Patient characteristics were assessed with a variety of measures including SCID I and II. The FAS and PCM shared 25% of the variance for patients and 14% for relatives, suggesting a conceptual overlap, but they may not assess identical constructs. The number of previous mood episodes, current self-rated manic symptoms, and comorbid symptoms of Cluster C personality disorder predicted patient-rated FAS. Relative-rated FAS was only predicted by comorbid symptoms of Cluster A personality disorder. In BD, specific patient characteristics seem to be linked to key aspects of EE even when in remission. However, it might depend whether the patient, his/her relative, or a neutral observer assessed EE.

Couples living with type 1 diabetes: An integrative review of the impacts on health and wellbeing

Impacts of type 1 diabetes and relationship factors on health and wellbeing of both persons with diabetes and partners (T1D partners) have not been investigated. Integrative review methods evaluated the evidence. From 323 titles, we included 24 studies involving 16,083 persons with diabetes and 1020 T1D partners. Studies were quantitative (n = 13), qualitative (n = 9) and mixed methods (n = 2). Maintaining resilient, good quality, intimate relationships optimises physical and psychological outcomes for persons with diabetes. Partners experience disturbed sleep and while general psychological health is maintained, distress surrounding hypoglycaemia is overwhelming for over a third of partners. Nurturing quality relationships could reap significant health benefits.

Factors influencing confabulation in Japanese patients with Alzheimer's disease

BACKGROUND

Confabulations are often observed in patients with Alzheimer's disease (AD) and can increase family caregivers' burdens. Previous studies have focused on the relationship between confabulation and cognitive ability. However, few studies have investigated the association between confabulation and familial factors. Here, we aimed to examine whether confabulation relates to familial factors, such as the level of family caregivers' expressed emotion or the level of functioning of the family.

METHODS

Twenty-seven outpatients with AD and their family caregivers participated in this study. We examined confabulations about episodic memory, semantic memory, and future planning using the Modified Confabulation Battery (MCB). We investigated correlations between scores on the MCB and scores on the Mini-Mental State Examination (MMSE), Geriatric Depression Scale (GDS), Family Attitude Scale (FAS), and the Family Adaptability and Cohesion Evaluation Scale. Multiple regression analyses were performed using the total scores on the MCB and domain-specific scores on the MCB as dependent variables, and the scores on the MMSE, GDS, and FAS as independent variables.

RESULTS

MCB scores were positively related to FAS scores (P < 0.01) and negatively to GDS scores (P < 0.05), but not to MMSE scores. Regarding the three domains the MCB measured, confabulation about episodic memory and future planning showed a positive relationship with FAS scores.

CONCLUSIONS

Family attitude was the factor most related to confabulation in our study. Patients with AD may attempt to avoid confronting family caregivers' high emotional expression through confabulation, or confabulation itself might result in high emotional expression among family caregivers. Psychoeducational or therapeutic approaches for family caregivers might reduce confabulation in patients with AD.

Positive Sides of the Disease: Posttraumatic Growth in Adults with Type 2 Diabetes

Type 2 diabetes is a chronic disease that can causes positive changes, as well as psychological distress. The aim of the this study is to investigate the posttraumatic growth level of adults with type 2 diabetes and to identify the relationship among perceived social support, coping, diabetes management self-efficacy, perceived expressed emotions, and PTG in diabetes patients from non-western, developing country. The findings revealed that patients experience a moderate level of posttraumatic growth. Regression analyses showed that the severity of the disease, educational level, perceived social support, problem-focused coping, optimistic coping and the criticism/hostility dimension of expressed emotions were associated significantly with posttraumatic growth. In the conclusion part, these findings were consistent with the posttraumatic growth theory. The study reveals that professionals aiming to increase the posttraumatic growth of diabetes patients may need to focus on and facilitate perceived social support, adaptive coping strategies, and perceived expressed emotions to facilitate growth experiences.

Religious Coping and Glycemic Control in Couples with Type 2 Diabetes

This study examines the role of religious coping in couples' diabetes management processes. Eighty-seven couples where one spouse had type 2 diabetes were surveyed. The relationships between religious coping (positive and negative), shared glycemic control activities (e.g., planning a healthy diet), and glycemic control were examined using repeated measures ANOVA and SEM. Findings show spousal engagement in shared activities is significantly associated with glycemic control. Furthermore, the use of negative religious coping by the diabetic spouse, and positive religious coping by the nondiabetic spouse, related to lower levels and higher levels of shared glycemic control activities, respectively. Religious coping and shared glycemic control activities appear integral to couples managing type 2 diabetes and, may serve as useful points of intervention.

Expressed Emotion in relatives of persons with dementia: a systematic review and meta-analysis

OBJECTIVES

Expressed Emotion (EE) refers to a number of key aspects of interpersonal relationships which have been shown to relate to outcomes in relatives of people with health conditions.

DESIGN

A systematic review and meta-analysis of EE and outcomes in relatives of persons with dementia is reported. Potential research studies were identified via a search of three electronic databases; PsychINFO, MEDLINE and the Web of Science between 1960 and 2015.

RESULTS

We reviewed 12 studies investigating correlations between EE and well-being in relatives of patients with dementia. Factors hypothesised to influence EE including attributions, social support, coping strategies and relationship quality were also reviewed.

CONCLUSION

High-EE relatives were found to have increased levels of burden (Z = 6.967, P < 0.001) and greater levels of depression (Z = 5.842, P < 0.001). Compared to low-EE relatives, high-EE relatives were more likely to attribute the patient's problems to factors that were personal to and controllable by the patient. Relatives with less social support, inefficient coping strategies and a poor relationship with the patients, were more likely to be classified as high-EE.

The impact of significant other expressed emotion on patient outcomes in chronic fatigue syndrome

Objective: Previous literature has identified the importance of interpersonal processes for patient outcomes in chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME), particularly in the context of significant other relationships. The current study investigated expressed emotion (EE), examining the independent effects of critical comments and emotional overinvolvement (EOI) in association with patient outcomes. Method: Fifty-five patients with CFS/ME and their significant others were recruited from specialist CFS/ME services. Significant other EE status was coded from a modified Camberwell Family Interview. Patient outcomes (fatigue severity, disability, and depression) were derived from questionnaire measures. Forty-four patients (80%) completed follow-up questionnaires 6-months after recruitment. Results: Significant other high-EE categorized by both high levels of critical comments and high EOI was predictive of worse fatigue severity at follow-up. High-critical EE was associated with higher levels of patient depressive symptoms longitudinally; depressive symptoms were observed to mediate the relationship between high critical comments and fatigue severity reported at follow-up. There were higher rates of high-EE in parents than in partners, and this was because of higher rates of EOI in parents. Conclusions: Patients with high-EE significant others demonstrated poorer outcomes at follow-up compared with patients in low-EE dyads. One mechanism for this appears to be as a result of increased patient depression. Future research should seek to further clarify whether the role of interpersonal processes in CFS/ME differs across different patient-significant other relationships. The development of significant other-focused treatment interventions may be particularly beneficial for both patients and significant others.

Expressed emotion among relatives of chronic pain patients, the interaction between relatives' behaviours and patients' pain experience

BACKGROUND

Chronic pain is a sensory and emotional experience that causes significant disturbances to a patient's life as well as to their family. Whether the family environment is affected by chronic pain and, in turn, affects the patients' pain experience has yet to be investigated. The interaction between patients and spouses has been assessed using the expressed emotion (EE) construct, a tool previously described in the field of mental health. For schizophrenia and other psychiatric illnesses, a correlation exists between family EE and patients' outcomes.

AIMS

The main objective of this study was to observe the presence of EE among relatives of chronic spinal pain patients and to evaluate its correlation with their symptoms.

METHODS

A prospective observational study was conducted on 54 patients and their spouses currently seen at the Chronic Pain Unit of Hospital Clinic of Barcelona. The following variables were recorded: age, gender, pain score, quality of life and EE.

RESULTS

Data showed that a considerable proportion of spouses were rated as high EE. There was an association between EE and patients' quality of life, and the level of EE predicted some other variables of patients' quality of life.

CONCLUSION

The EE level of spouses of chronic pain patients affects the patients' quality of life and thus the way that they experience their pain.

Couple's relationship with diabetes: means and meanings for management success

Diabetes is a serious chronic illness that involves individuals, couples, and families in complex reciprocal interactions with the illness and other life dimensions. A major issue in diabetes management is how well the patient is able to follow the established medical regimen of selfcare. Situated within personal, physical, and social contexts, the meaning that a couple creates and the emotions they feel in their adaptation to living with diabetes and its demanding regimen can be viewed as the couple's relationship with diabetes.

Attributions for negative events in the partners of adults with Type 1 diabetes: Associations with partners' expressed emotion and marital adjustment

OBJECTIVES

An attribution-emotion model of reactions to illness was tested in a sample of partners of 60 adult patients with type I diabetes.

METHODS

Partners were interviewed using the Camberwell family interview (CFI), from which spontaneous attributions for negative events were extracted and coded. Events were classified into diabetes and non-diabetes events. Partners also completed questionnaire measures of marital adjustment, anxiety and depression.

RESULTS

Compared with low expressed emotion (EE) partners, high-EE partners attributed proportionally more negative diabetes events (e.g. patient characteristics and behaviour) to factors controllable by and personal to the patient. High-EE partners were more anxious than low-EE partners, and made more responsibility attributions (attributions rated as both internal and controllable and personal). Partners with poorer marital adjustment made more responsibility attributions, but only for non-diabetes events.

CONCLUSION

Whereas attributions for both diabetes and non-diabetes events were related to partners' EE, attributions for diabetes events were not significantly associated with partners' marital adjustment.

Lived experience of significant others of persons with diabetes

AIM

To elucidate the lived experience of being a significant other of a person with diabetes.

BACKGROUND

A person's illness has consequences not only for the affected. Despite an increasing number of studies on significant others, there have been few about the experience of being a significant other of a person with diabetes.

DESIGN

Phenomenological-hermeneutic approach.

METHOD

Fifteen significant others of persons with diabetes were interviewed. The interviews were conversational, starting with an open question. They were audiotaped and transcribed verbatim. The texts were analysed and interpreted.

RESULTS

The meaning of the lived experienced as narrated by the significant others is presented by way of four major themes: living in concern about the other's health, striving to be involved, experiencing confidence and handling the illness. Many significant others said that they lived a normal life and had come to accept diabetes as a normal part of life. At the same time, the significant others experienced sorrow when they saw the health of the person with diabetes deteriorate over time.

CONCLUSIONS

Living near a person with diabetes meant being constantly attentive to how the person was feeling. The significant others wanted to be involved in the illness by the persons with diabetes and healthcare staff. They felt confidence both in the way the person with diabetes handled the illness and in the ongoing research about diabetes. The significant others had found ways to handle the illness but lacked support from healthcare staff.

RELEVANCE TO CLINICAL PRACTICE

Nurses need to provide support for significant others as well as good caring for the patients and this requires a profound understanding of significant others from their own perspective.

Idiosyncratic personal explanations for blood glucose events are associated with poorer self-management and glycemic control in adult patients with long-standing type 1 diabetes

OBJECTIVE

To examine whether spontaneous causal attributions for blood glucose events were associated with blood glucose control (HbA(1c) [A1C]), self-management, and adjustment to diabetes.

RESEARCH DESIGN AND METHODS

A total of 62 adults (31 female) with type 1 diabetes, recruited from a diabetes specialist clinic, with a mean age of 42.3 years and a mean illness duration of 19.6 years, were interviewed about the onset, history, course, and management of their diabetes. Spontaneous causal attributions for fluctuations in blood glucose level were extracted from the interviews and coded in accordance with the Leeds Attributional Coding System. Participants completed questionnaire measures of anxiety, depression, and appraisal of diabetes. Glycemic control (A1C) at the time of interview and 1 year later was extracted from notes.

RESULTS

Participants who made proportionally more personal, or idiosyncratic, explanations for blood glucose fluctuations or events (such as hypoglycemic episodes) had higher A1C levels at time 1 and 1 year later and were judged to manage their diabetes less well. Furthermore, the association between personal attributions and A1C was partly accounted for by self-management behavior. Participants who made personal and stable attributions appraised their diabetes more negatively.

CONCLUSIONS

Clinicians should be sensitive to patients' causal explanations for blood glucose events. Helping patients consider alternative explanations may produce benefits in terms of better management and control of diabetes.

Improving self-management in insulin-treated adults participating in diabetes education. The role of overprotection by the partner

AIMS

To examine the role of overprotection by the partner--i.e. excessive protection, unnecessary help, excessive praise for accomplishments, or attempts to restrict activities as a consequence of underestimating the patient's capabilities--in changes in patient self-management in the context of diabetes education.

METHODS

Sixty-seven insulin-treated patients with a partner completed questionnaires on admission to a Multidisciplinary Intensive Education Programme (MIEP) and 3 months after completing the core module of MIEP. Factors assessed were overprotection by their partner and three aspects of diabetes self-management, namely internal locus of control, diabetes-related distress and HbA1c. Regression analyses were used to test the independent associations of patient sex, baseline overprotection and the interaction between sex and overprotection with diabetes self-management at the follow-up stage, controlling for the baseline value of the dependent variable.

RESULTS

The increase in internal locus of control and decrease in HbA1c were both significantly less for female patients who perceived their partner to be rather overprotective than for female patients who did not perceive their partner to be overprotective. The more patients, both male and female, perceived their partner to be overprotective, the less their diabetes-related distress decreased.

CONCLUSIONS

Overprotection by the partner showed a negative association with improvement in diabetes self-management, especially for female patients. Thus, an intervention programme with the aim of reducing overprotection by the partner, or the perception of this, may enhance self-management in patients participating in diabetes education.

Teachers' emotional expression about disruptive boys

OBJECTIVES

To assess teachers' emotional expression about pupils using the Five Minute Speech Sample (FMSS) and coding procedures for parental expressed emotion (EE). To compare EE for disruptive and non-disruptive pupils.

METHOD

Twenty-one teachers provided speech samples for both a disruptive and a non-disruptive pupil in their class selected using standard behaviour rating scales.

RESULTS

Teachers' emotional expression was reliably measured using EE codings. Teachers displayed no emotional overinvolvement (EOI) and made few critical comments. High EE, characterized by criticism and a lack of positive comments, was associated with children's behavioural difficulties. Multiple regression suggested that conduct problems rather than hyperactivity were associated with high EE.

DISCUSSION

Results support the application of certain elements of the EE construct to teachers' emotional expression about pupils. However, there was an absence of EOI and a lack of association between relationship and other EE categories. The absence of this association suggests that EE might be most usefully considered as a measure of teachers' emotional response to pupils, rather than the emotional quality of the teacher-pupil relationship.

Expressed emotion and attributions in the carers of patients with Alzheimer's disease: the effect on carer burden

Burden of care, expressed emotion (EE), causal attributions, and salivary cortisol were assessed in 100 carers of patients with Alzheimer's disease. Forty-one carers were rated high EE, which was associated with higher scores of carer distress and strain, and greater reports of noncognitive features in the patient, but not with cortisol levels. High EE carers made more attributions personal to, and controllable by, the patient for negative events. Critical carers made more attributions of the patient's behavior that was idiosyncratic. Warmth toward the patient was associated with the opposite of this pattern. Overinvolved carers made attributions of the patient's behavior to causes external to the patient and internal to themselves. Cortisol levels were associated with self-reports of strain and distress.

The effect of parental expressed emotion on glycaemic control in children with Type 1 diabetes. Parental expressed emotion and glycaemic control in children

OBJECTIVE

To measure expressed emotion (EE) in parents of young children with diabetes and to examine the relation between EE and glycaemic control in children with Type 1 diabetes in a longitudinal study over 24 months. We hypothesised that good glycaemic control, as measured by low glycated haemoglobin levels, would be predicted by high parental emotional over-involvement, low frequency of critical comments and absence of hostility. We predicted that these effects would be stronger in maternal than paternal scores.

METHODS

Forty-seven children attending a Paediatric Diabetes Clinic and their parents were studied over 24 months. Glycated haemoglobin was measured on three occasions, at the start of the study period, 12 and 24 months later. At 12 months, parental EE was measured using an adapted version of the Camberwell Family Interview, and child emotional and behavioural problems were measured using the parent version of the Child Behavior Checklist. Multiple regression models were used to test the hypotheses.

RESULTS

Forty-three maternal and 33 paternal interviews of adequate quality for analysis were obtained. Paternal hostility was found to be associated with elevated glycated haemoglobin measured 12 months before interview and 12 months after interview, accounting for 22% and 29% of the variation in glycated haemoglobin respectively.

CONCLUSIONS

We did not find that parental emotional over-involvement or criticism predicted glycaemic control. Presence of hostility was important, but in contrast to our hypothesis, this was paternal rather than maternal hostility. We suggest that (i) relatively absent, rejecting fathers play little role in diabetes management and children perceive this negatively, or (ii) mothers who are unsupported by fathers cannot in turn support their children in diabetes care.