Comparison of Dependence in Daily Life Activities , Quality of Life and Caregivers ' Expressed Emotions in Schizophrenic Patients with and without Relapse

Schizophrenia is a chronic, relapsing disease, characterized by adverse set of signs and symptoms that strongly affect the patient functional behaviors, quality of life, and quality of caregivers emotional responses. The aim of this study was to explore the differences between dependence in activities of daily life, quality of life (QOL), and expressed emotion (EE) in schizophrenic patients with and without relapse. A retrospective case-control design was utilized in this study. It included 120 schizophrenic patients and their caregivers divided into two groups. The group with relapse consisted of 60 schizophrenic patients with history of recent relapses and their caregivers and the group without relapse included 60 patients. The tools used for data collection were interview questionnaire sheet, QOL scale for patients, and Camberwell family interview for caregivers. The results revealed that there were statistically significant differences between the two groups of caregivers under study regarding their expressed emotions, relapse group had more problems related to work than non relapse, more relapse patients had low QOL, compared to group without relapse. Also, the QOL scores had a negative statistically significant correlation with the number of relapses. It is concluded that patients group with relapse have more dependence in activities of daily life, lower QOL, and their caregivers have higher expressed emotions. Thus, it is necessary to train caregivers of schizophrenic patients regarding expressed emotions and how to control them for the safe of better prognosis and lower susceptibility to relapse among their patients.


INTRODUCTION
and negative symptoms. (1)The clinical course following a first psychotic episode often fluctuates with periods of psychotic remissions, as well as psychotic exacerbations and relapses, and the degree of work and social impairment is highly variable among patients. (2)lapse is a deterioration or recurrence of positive rather than negative features.It appears to impair the course of the disease.Impairment is often longer than expected for those patients who discontinue antipsychotic medication; they then relapse to their pre-discontinuation clinical state of function. (3)Psychosocial factors mean psychological development in, and interaction with a social environment.Psychosocial factors include quality of life, stigma, expressed emotions (EE), psychological effects, depression, self-esteem, relationships, role change and impact on careers, identity and sense of self, disability, functionality and lifestyle changes. (4)ality of life (QOL) is known to be indicative of the level of social functioning in mental health persons.It can be defined as an overall sense of wellbeing, which is comprised of both objective and subjective evaluations of physical, material, social and emotional wellbeing, together with personal development and purposeful activity. (5)atients with schizophrenic symptoms and poor personal and social functioning have a farreaching impact on their own quality of life, while the nature of schizophrenia and its early onset often impoverish the lives and lifestyles of those who care for them. (6) as a concept reflects the emotional atmosphere of home environment.The three attitudes pertaining to expressed emotion are known as hostile, critical comments, and emotional over-involvement.The attitudes of the relatives determine the direction of the illness after treatment.Relatives' negative comments and non-verbal actions with a patient are stressful on the recovery of this patient. (7) has been demonstrated that relapse could be expected in 70% of patients after the first schizophrenic episode; in parallel 70% of patients show an incomplete remission of the disorder after the first episode. (4)The risk for a relapse after a schizophrenic episode remains increased throughout patient's lifetime.Moreover, the risk of chronicity increases with every relapse of the patient. (3)

Lehman Quality of Life Interview:
The scale was developed (13) and modified accerdiy to Ghaith 2005 (14) .It was used to Responses were checked on a 4-point Likert Scale: always, usually, rarely, and never.A higher score means better QOL.
Items were scored 0, 1, 2, and 3 for the responses never, rarely, usually, and always respectively.The scores were reversed for negative items.For each domain of factors, the scores of the items were summed-up and the total divided by the number of the items, giving a mean score for the part.These scores were converted into a percent score.
The QOL was considered high if the percent score was 50% or more, and low if less than 50%.

Pilot study
A pilot study was carried out on twelve patients (6 with relapse and 6 without

RESULTS
Table 1 shows that both groups had a mean age around 34 years, with a majority of males.More than half of the patients in both groups had basic to secondary education, were working, and were single or divorced.The majority were residing in urban areas.

DISCUSSION
The current study demonstrated that the highest percentage of the group with relapse and group without relapse had age between 30 and 50 years (Table 1).This is in line with previous literature which indicated that schizophrenia typically begins in late adolescence or early adulthood.On the same line, many studies revealed that the onset of psychotic symptoms is usually during adolescence or early adulthood. (15)wever, the initial decade of illness is generally marked by repeated episodes of psychosis with partial and variable degrees and duration of inter-episode remission with occurrence of disability with each episode of illness . (16)cording to the present study, more patients in the group with relapse were partially or totally significantly dependent, compared to those in the group without relapse (Table 4).This may be due to that schizophrenia cause marked change in this would increase their dependence on others in their activities of daily living. (3)ncerning caregivers expressed emotions, the present study indicated that the majority of caregivers of the group with relapse had high level of expressed emotions, which was significantly higher, compared to those of the group without relapse (Table 5).This finding is quite expected since high expressed emotions reflect lack of coping and negative attitude of caregivers towards patients, which would increase their susceptibility to relapse.It also implies that caregivers could not take the proper action in case of symptoms increase as seeking professional help, but instead may go to "sheikh" or traditional healers and thus increase the relapse rate among schizophrenic patients.Also their avoidance of social interaction could pose a burden and stress to caregivers who always blame patient as they had a significant role in their problem.This would result in disturbed relationship with the patient and increased vulnerability to relapse (3) The finding of the present study revealed that there were statistical significant positive correlations between number of hospitalization and caregivers' expressed emotion.This relationship between number of hospitalization and increased expressed emotion could be reciprocal.Thus, increased expressed emotions could lead to more relapses, with associated more frequent hospital admission.On the other hand, the repeated hospitalizations could increase the burden on family caregivers, and could be reflected in higher expressed emotions among them.In agreement with this, the studies revealed that the direct effects of hospitalization and the resulting psychosocial consequences place a huge burden on caregivers and relatives and may lead to difficulties in their relationship with the patient. (17) for the time since last hospitalization, the present study demonstrated a statistically significant negative correlation between this time since last hospitalization and caregivers' expressed emotions (Table 7).This could be explained by the association between the length of time since last hospitalization and the remission of symptoms.
Schizophrenic patients who are stable and controlled do not actually need frequent hospitalizations, and thus take longer times of quiescence between the hospitalization episodes.This period of quiescence is certainly associated with lower burden on caregivers, and thus could decrease their expressed emotions.
In agreement with this, the studies reported that patients with schizophrenia who experience repeated relapse typically characterized by exacerbation of psychosis and re-hospitalization can have significant impairment of their psychological functioning, including poor social interaction, particularly difficulty maintaining relationships with family and friends, or functioning in the workplace. (18)l these would lead to higher expressed emotions among their caregivers.
The present study has also demonstrated that the group with relapse had significantly lower QOL scores concerning work and daily activities, compared to the group without relapse.Moreover, a statistically significant negative correlations was revealed between the total number of relapse episode, and the number of relapses in the last year and QOL scores (Table 7) ,this means that the repeated frequent relapses have a negative impact on patient QOL.These findings agreed with, another study which found that there was a statistically significant positive Bull High Inst Public Health Vol.40 No. 2 [2010]   correlation between fewer number of episodes and high scores of quality of life. (19)e current study indicated that the

CONCLUSION AND RECOMMENDATIONS
In conclusion, the comparison of the Group with relapse and group without relapse revealed that group with relapse have more dependence in activities of daily life, lower QOL, and their caregivers have higher expressed emotions which was positively related to the number of hospitalizations.
In view of theses findings, it is Schizophrenic disorders are characterized in general by fundamental and characteristic distortion of thinking perception, and affects that are inappropriate or blunted Clear consciousness and intellectual capacity are usually maintained although certain cognitive deficits may evolve in the course of time.The most important psycho-Bull High Inst Public Health Vol.40 No.2 [2010] pathological phenomena include thought echo, thought insertion or withdrawal, thought broadcasting, delusional perception and delusions of control, influence of passivity, hallucinatory voices, completely self-dependent, partiallydependent, and completely-dependent.Camberwell Family Interview:This tool was originally used to obtain detailed information about "Expressed Emotion" from caregivers of patients in response to patients' illness .(10)and the formal version of the tool was developed.(12)The Arabic version used in the present study was previously developed.(11)It consisted of the following categories and components: a) psychiatric symptoms of schizophrenic patients as reported by caregivers.This category has the following 4 subcategories with a total items of 56: Loss of control over behavior (6 items), Patient's feeling of sadness and depression (7 items), Relating with others (4 items), Patient's social behavior (4 items), and Patient's physical disorders (9 items); b) disturbed patient's daily program: includes Work (3 items), Recreation (3 items), Domestic duties (4 items); c) Inadequate family management of patients' illness: includes family reaction to patient's behavior (7 items) , and action taken by family (9 items); Bull High Inst Public Health Vol.40 No.2 [2010] Items were scored 0, 1, 2, and 3 for the responses never, rarely, usually, and always, respectively.The scores of the items were summed-up and the total divided by the number of the items, giving a mean score.These scores were converted into a percent score.The expressed emotions were considered high if the percent score was 50% or more, and low if less than 50%.
assess the life circumstances of persons with severe and persistent mental illness in terms of what they actually do and experience "objective quality of life" and their feelings about this experience "subjective quality of life or life satisfaction."It consisted of 49 items divided into six subscales: performance at work (7 items), activities of daily living (7 items), social relations (13 items), personal hygiene (5 items), interest in surrounding events (7 items), and interest in recreational activities (10 items).
relapse) and their caregivers to test the feasibility of the study and the clarity of the tools.The pilot study also helped to know the time needed for filling the forms.Fieldwork The actual fieldwork started after an approval was obtained to conduct the study from the directors of El-Abassia Governmental Hospital for Mental Health to facilitate data collection.Once permission was granted to proceed in the study, the researcher contacted each patient and his/her caregiver individually.At the same time, the purpose and nature of the study were explained.A semi-structured interview with each patient and his/her caregiver, the questionnaires were read, explained and the choices were recorded by the researcher.Each patient was interviewed individually for about 60 minutes twice weekly.For more validation of information, the interview was done in the presence of the psychiatrist.Also, patient's file was used to help in completion of needed information.Data collection was completed over a six-month period, from May to October 2009.Administrative design and ethical considerations Official letters to conduct the study were addressed from the Faculty of nursing to the directors of El-Abassia Governmental Hospital for Mental Health.Participants were informed about the purpose of the study and voluntary participation and confidentiality were ensured.They were also informed about their rights to refuse or accept to participate.
patient's behavior, which makes them socially isolated, neglecting of their personal hygiene, verbally abusive and threatening to cause harm to self and others.These deviated behavioral symptoms are often observed during relapse or a prodroma to relapse.This is consistent with another study which added that such patients fail to adhere to regular time schedules, are generally uncooperative, verbally abusive, and making unreasonable demands.Thus, relapsed patients had more severe deterioration at work, along with the deterioration of the ability to concentrate, length of time since last relapse was positively correlated with the QOL score which indicates that a shorter time since last relapse is associated with lower QOL score.This is quite plausible since relapse is associated with exacerbation of psychotic symptoms, which may require hospitalization and affect most of the patient's life aspects.This finding is consistent with another study which highlighted that relapses in schizophrenia predict poor prognosis, bring about deterioration in social, occupational, and financial status and increase the burden of care on the family, i.e. negatively affect patient's QOL(3).
recommended to train caregivers of schizophrenic patient regarding expressed emotions and how to control them for the safe of better prognosis and lower susceptibility to relapse among their patients.Thus, this needs efforts from the psychiatric nurse who should be able to counsel schizophrenic patient's family caregivers, and would necessitate training programs for nurses to master the counseling skills.The long-term effects of counseling family caregivers regarding expressed emotions on the occurrence of relapse could be then investigated in future research.