Indian Journal of Psychiatric Nursing

: 2022  |  Volume : 19  |  Issue : 1  |  Page : 47--53

Family attitude toward the persons with negative symptoms of schizophrenia

Chanamthabam Padmini Roy, Arunjyoti Baruah 
 Department of Psychiatric Nursing, LGB Regional Institute of Mental Health, Tezpur, Assam, India

Correspondence Address:
Chanamthabam Padmini Roy
Department of Psychiatric Nursing, 3rd Floor, Academic Building LGB Regional Institute of Mental Health, P O Tezpur, Sonitpur, Tezpur - 784 001, Assam


Background: Negative symptoms of schizophrenia not only lead to poor interpersonal relationship, impaired social and work functioning of the clients but it also affects family members in various aspects. The present study aimed to assess the attitudes of the primary caregivers toward the clients with negative symptoms of schizophrenia. Materials and Methods: A cross-sectional study was conducted at tertiary care hospital of Assam. Through purposive sampling technique, 40 primary caregivers of clients with negative symptoms of schizophrenia were selected from the indoor setting of a tertiary mental care institute. Self-structured sociodemographic and clinical Proforma, Positive and Negative Syndrome Scale (PANSS), Scale for Assessment of Negative Symptoms (SANS), and Family Attitude Scale (FAS) were used to collect the data. Data were analyzed using the descriptive and inferential statistics. Results: Majority of the participants (87.5%) score <60 in the FAS which showed low expressed emotion toward the clients with negative symptoms of schizophrenia. A significant negative correlation was found between the SANS score and monthly income of the clients (r = -'0.446, P = 0.004). Conclusion: Attitude of the primary caregivers toward the patient may vary based on the symptoms of schizophrenia. Assessing their attitude in the form of expressed emotion may help to understand their perception during the care of patients with negative symptoms of schizophrenia. This may help to plan suitable psychosocial nursing care for the primary caregivers.

How to cite this article:
Roy CP, Baruah A. Family attitude toward the persons with negative symptoms of schizophrenia.Indian J Psy Nsg 2022;19:47-53

How to cite this URL:
Roy CP, Baruah A. Family attitude toward the persons with negative symptoms of schizophrenia. Indian J Psy Nsg [serial online] 2022 [cited 2023 May 28 ];19:47-53
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Schizophrenia is regarded as a severe, brain disorder that affects functioning abilities of an individual in the areas such as self-care, interaction, interpersonal contact, family, societal, and work-related area.[1] Due to the nature of the illness, the family members and care providers also experience many challenges and burden in different aspect while rendering care for the patients. In a study by Kumar and Saini[2] found that, 43.8% of the caregivers of mentally ill patients perceived moderate level of burden and 31.3% experienced severe level of burden.

National Mental Health Survey of India, 2015–2016 conducted in Assam also found that the lifetime and current prevalence of schizophrenia and other psychotic disorders were 1.53% and 0.50%.[3]

The symptoms of schizophrenia are diverse in nature and can be divided into three areas: Positive, negative, and cognitive symptoms.[4] Intensity and impact of all these symptoms also varies from one another. Positive symptoms lead to acute exacerbations of symptoms and relapse whereas negative and cognitive symptoms lead to chronic disability. In addition to these, social and economic impact of the disorder on families and society is massive.[5] Negative symptoms are found to be common and usually not <1 negative symptom was noted in up to 90% of patients in the first psychotic episode, while 35%–70% of patients sustained to have clinically significant negative symptoms that persisted after treatment.[6] Despite the better understanding of schizophrenia restricted treatment options are available for negative symptoms unlike the positive symptoms. Because of this it imparts a poorer outcome, higher burden and found more distressing for family members.[6],[7] Due to all these factors, unmet therapeutic challenge may be critical for the long-term outcome of schizophrenia.[8]

Emergence of deinstitutionalization concept brought more responsibilities to the family members of persons with schizophrenia. Family responses toward positive and negative symptoms of schizophrenia may differ. Negative symptoms may result in more burden on relative than positive symptom as relatives tend to think that the symptoms are under the control of the clients.[9] Family members and caregivers show varied reactions and attitude toward their clients with schizophrenia.Sargeant[10] found that family members face a challengingg task to cope up with adversly affected social life and violence directed towards the family members. Barrowclough and Tarrier[11] also found that poor social functioning was reported among the clients who stay with hostile relatives. Weisman et al.[12] reported that high expressed emotion families of schizophrenia patients viewed illness and associated symptoms under patient control and symptoms reflecting behavioral deficits like poor hygiene were criticized more than symptoms like hallucinations. Bustug[13] also found that perceived criticism/hostility by patient being the risk factor on the positive, negative symptoms and on the total score of Positive and Negative Syndrome Scale (PANSS).

However, the findings were not consistent. Glynn et al.[14] found no significant differences were associated with the global items of negative symptoms and level of relatives' high expressed emotion. Although the frequency of critical comments were associated with Scale for assessment of negative symptoms (SANS), global items of negative symptoms measuring anhedonia/associality.

Negative symptoms unlike the positive symptoms persist for a longer period of time and may impose more burdens to the caregivers/family members. Attitude of the primary caregivers may differ due to the symptoms and nature of the illness. Finding a relationship between these may provide evidence to the existing reviews. The study was carried out to find out the negative symptoms of schizophrenia and the family attitude of their primary caregivers. The study also aimed to find any association of family attitude of primary caregivers with the sociodemographic and clinical variables of persons with schizophrenia.

 Materials and Methods

Study design

Researcher adopted a cross-sectional design for the study. The study was approved by the Institutional Ethics Committee (IEC no 296 vide letter no LGB/ACA/ETC/2560/07/1614) and written informed consent was obtained from all the participants before the data collection. The data collection was carried out from 29/08/2019 to 08/09/2020.

Setting of the study and Sample

The study was carried out in a tertiary care mental health institute in the north-eastern part of the country. The services provided in the hospital includes OPD, inpatient department, Emergency, Special Clinic for Geriatrics, Epilepsy, Somatoform disorders, Memory Clinics, COVID-19 Psychosocial Services Tele helpline, Community and Rehabilitation Services, Forensic Psychiatry, Child and Adolescent Psychiatry and Center for De Addiction Medicine. Patients with varied psychiatric diagnosis came to seek treatment. As per the hospital record schizophrenia is one of the most common major psychiatric disorders came for treatment in the hospital. To provide comprehensive care family members should be taken into consideration and will help in the better plan of nursing care. In the indoor setting, the researcher screens the patients for the negative symptoms of schizophrenia. Forty primary caregivers of those screened patients who fulfill the inclusion and exclusion criteria were purposively selected for the present study. Primary caregivers above 18 years of age, both genders and who had provided care to the clients for more than 1 year are included in the study. Those primary givers who had any physical and mental illness are excluded from the study.

Description of the tools

Sociodemographic and clinical pro forma for clients and sociodemographic pro forma for primary caregivers was develop by the researcher through the intensive reviews and validated from five experts of related fields.

Positive and Negative Syndrome Scale

It is a 30-item 7-point Likert scale. It consists of 7 positive, 7 negative and 16 general psychopathology subscale and total scores is obtained by summation of ratings across the components. Composite scale score denotes the degree of predominance of one syndrome over another.[15]

Scale for assessment of negative symptoms

It is a 6-point scale which measures negative symptoms on a 25 item. Items are listed under the five domains, i.e., affective blunting, alogia, avolition/apathy, anhedonia/asociality, and attention. It is found to have good reliability in the same population.[16]

Family attitude scale

It is 30 items self-administered, 4-point Likert tool developed by Kavanagh et al. to measure the core dimensions of expressed emotion. Its rating showed good correlation with Camberwell Family Interview in both Western and Asian families of schizophrenia patients.[17] In this study, it is used to measure expressed emotion. Score ranges from 0 to 120, with higher scores indicating higher levels of burden or criticism.[18] In the previous study, it was found score of 60 and above predicted relapses among the patients.[19] The reliability coefficient values were found to be satisfactory. English version of the FAS tool was translated into Assamese language. The translated FAS were validated by the experts and reliability of the tool was checked in the same population. The translated tool was validated, and Chronbach's alpha of the translated tool was found to be 0.75.

Data collection procedure

The researcher recruited the admitted patients with the diagnosis of schizophrenia. On the 5th day of the admission psychopathology of the patients were assessed individually through the PANSS and SANS scale. Primary caregivers whose patients had predominance negative symptoms on the composite scale of PANSS and who fulfilled inclusion and exclusion criteria were selected for the study. Intention of the study was explained, and written informed consent was obtained from the participants. Sociodemographic and clinical pro forma information was collected through the interview technique from the participants and client's case file. Respondents rated themselves on the self-rated FAS and took around 20–25 min to complete.

Statistical analysis

Collected data were tabulated, and frequencies, range, mean, and Chi square and Fisher's exact t-test were applied wherever it is required, and correlation coefficient test were computed. Statistical Packages for the Social Sciences software version (SPSS) 20 was used for the analysis of data.


[Table 1] and [Table 2] described the sociodemographic, clinical variables of persons with negative symptoms of schizophrenia in terms of frequency and percentage.{Table 1}{Table 2}

[Table 3] described the mean, standard deviation of selected sociodemographic, clinical variables of persons with negative symptoms of schizophrenia and their.{Table 3}

[Table 4] shows the sociodemographic variables of primary caregivers of persons with negative symptoms of schizophrenia in terms of frequency and percentage.{Table 4}

[Table 5] described the mean, standard deviation and range of selected socio demographic variables of primary care givers.{Table 5}

[Table 6] presented the mean composite scale score of PANSS was (‒16.20 ± 6.73), mean score of SANS was (83.83 ± 15.3) and mean family attitude score was (44.42 ± 15.98).{Table 6}

[Table 7] shows that majority of the primary caregivers 35 (87.5%) had low expressed emotion toward the clients with negative symptoms of schizophrenia.{Table 7}

[Table 8] showed no significant association between FAS score and selected socio demographic and clinical variables of persons with negative symptoms of schizophrenia.{Table 8}

[Table 9] showed no significant association between FAS score and selected socio demographic variables of primary care givers.{Table 9}

[Table 10] showed a significant negative correlation between monthly income of family and total SANS score at 0.01 level of significance.{Table 10}

[Table 11] showed no significant correlation between FAS score and selected socio demographic variable of primary care givers.{Table 11}


The present study shows that mean score of positive symptoms of PANSS scale was 15.93 and mean score of negative symptoms of PANSS was 32.53. Participants had both positive and negative symptoms during the time of admission and the family members expressed that positive symptoms create more chaos and difficult to manage at home. Among the negative symptoms mean score of affective flattening was found to be 26.25 and participants mostly had poor eye contact, monotonic, lack of expressive gestures, and decreased spontaneous movements. The findings are supported by the literature by Bobes et al.[20] which revealed that the most prevalent negative symptoms were social withdrawal (45.8%), emotional withdrawal (39.1%), poor rapport (35.8%), and blunted affect (33.1%).

In the present study, the researcher found that low level of expressed emotion was present among the primary caregivers of persons with negative symptoms of schizophrenia. In a study conducted by Gogoi[21] found that, 79% of the family members of patients with schizophrenia had low expressed emotion.

The result of a study by Sadath et al.[22] reported that perceived stress significantly increases expressed emotion among the caregivers of patients with first episode non affective symptoms. Similarly, in a study conducted by Provencher and Mueser[23] reported that objective burden in the form of physical problems, financial difficulties and household tension was related to only severity of negative symptoms, whereas subjective burden was associated with both the severity of positive and negative symptoms.

Exhibition of the expressed emotion depends on the various factors such as caregiver age, caregiver's level of education, and employment status of the caregivers.[24],[25] The primary caregivers were middle age adults and they might have adequate physical strength to deliver better care for their clients. Due to the nature of illness schizophrenia treatment took longer period of time; therefore, having a source of income by the caregivers might help them to bare the expenses for their treatment. In the present study, it is also seen that most of the clients were already on treatment from mental health professionals before admission to the study setting, which may make them aware of the illness pattern and symptoms to some extent. All these factors might have contributed to the present study findings of low expressed emotion among the primary caregivers.

A significant negative correlation was found between the negative score of SANS and monthly income of family. The study finding is supported by Ran et al.[26] in China where it was reported that one of the predictors of longer duration of illness is low socio economic status of the family. Ran et al.[27] in a study among persons with schizophrenia it was reported that longer duration of illness, lower family socioeconomic status, living in a shabby house, lack of care givers and marked symptoms were the predictor of poor work functioning. Differing results were shown by Brown et al.[28] that there was no significant difference in the upper/middle social class with the lower social class in the areas of negative and thought disorganization symptoms.

Socioeconomic background of the clients has indirect effect on the negative symptoms among the early onset schizophrenia.[29] Clients from better socioeconomic status might have facilities for recreational and vocational activities which may improve their work functioning and social interaction.


There are the certain limitations of this study. The sample size of the study was small; therefore, the study findings cannot be generalized. The study population comprised of only the primary care givers who accompanied the patient during the time of hospital stay. There may be primary care givers at home who are involved in the care of the patient more expansively.


Assessment of perceived expressed emotions by the patients with negative symptoms of schizophrenia may give similar or contradictory results with the present study findings. Exploring the lived experiences of the primary caregivers with negative symptoms of schizophrenia may help to understand in an expansive manner.


The present study shows that the primary caregivers' attitude in the form of low expressed emotion toward the patients with negative symptoms of schizophrenia. The family members play a vital role in the care and treatment of patients with schizophrenia. Understanding their behaviors toward the patients will help to understand their burden while rendering care for patients with negative symptoms. It will help to plan appropriate nursing interventions such as psycho education, stress management techniques, and enhancement of coping skills for the primary caregivers. Further research in this area with the larger sample size may give different outcome.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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