Psychopathology and personality factors in first-degree relatives of patients with schizophrenia.

BACKGROUND: Schizophrenia is a chronic mental illness which has far-reaching consequences not only on patients but also on relatives. These relatives are at an increased risk for developing schizophrenia, depression, and substance dependence. Psychopathology may be related to personality factors. This study was planned to assess psychopathology and personality factors in first degree relatives of patients with schizophrenia and to evaluate any relation between them.
MATERIALS AND METHODS: This was a cross-sectional study conducted at psychiatry out- and in-patient clinic at a tertiary care teaching hospital. One hundred and fifty patients who were first-degree relatives of patients diagnosed with schizophrenia on the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition were enrolled in this study. Psychopathology was assessed on "Symptom Checklist 90-Revised." "Big Five Inventory" (BFI) was used to study the personality factors. The two variables were compared to look for any relation between them.
RESULTS: Eighty-two of 150 (54.67%) first-degree relatives were diagnosed to have significant psychopathology. Among them, 42 (i.e., 58.5%) had either somatization or depression. Those relatives who had psychopathology scored higher on neuroticism (P = 3.51E-04) and lower on agreeableness (P = 0.029) domains of BFI.
CONCLUSION: Relatives of patients with schizophrenia should be screened for psychopathology regularly, also relation between personality and psychopathology needs to be explored further. Copyright:

Schizophrenia is a chronic mental illness in which learning, thinking, and behavior of a person are affected.[1] It has a lifetime prevalence of 0.3%–0.7%.[2] The prevalence of schizophrenia in India is around 2.6–3.4/1000 individuals, and incidence varies from 0.35 to 0.93/1000 in different studies.[34]

There is an increased genetic load in relatives of a patient with schizophrenia. They have a higher risk of developing schizophrenia, schizoaffective disorder, personality disorder, depression, and substance dependence.[56] The likelihood of relative developing schizophrenia is correlated with the closeness of the relationship to the patient ( first- or second-degree relative).[7]

Having psychopathology affects the overall well-being of the relative. Psychopathology may be related to personality factors. Personality and psychopathology can influence the presentation or appearance of one another or they can have a causal role in the development of one another.[8]

Few Indian studies have looked into the relation between personality factors and psychopathology of relatives of patients with schizophrenia hence this study was planned to assess psychopathology and personality factors in first degree relatives of patients with schizophrenia and to evaluate the relation between these two factors.

MATERIALS AND METHODS

Measures used

Semi-structured pro forma:

It comprised questions related to sociodemographic variables

Symptoms checklist 90 revised (SCL 90R):[910]

SCL 90R is a screening measure of general psychiatric symptomatology. It is a 90 item 5 point Likert scale having 9 subscales and a reliability of 0.62 to 0.89. It was used in the study to assess the psychopathology of relatives

Big five inventory (BFI):[11]

This questionnaire was used to measure the personality traits related to the Big Five personality factors: extraversion, agreeableness, conscientiousness, neuroticism, and openness to experience. It is a 44 item 5 point Likert scale with Cronbach's alpha 0.75 to 0.90.

Methodology

This was a cross-sectional study conducted at a tertiary care teaching hospital. Permission was taken from the Institutional Ethics Committee, and informed consent was obtained from all the participants. One hundred and fifty first-degree relatives of 150 patients diagnosed with schizophrenia on Diagnostic and Statistical Manual of Mental Disorders Fifth edition were recruited from the outpatient/inpatient psychiatry clinic. Convenience sampling was used to select the study participants. First-degree relatives comprised patients' parents or siblings or offsprings. As genetic load is correlated with the closeness of relationship to the patient, only first-degree relatives were included to provide homogeneity with respect to genetic loading. Adult relatives who had completed 18 years of age and were less than 55 years were included in the study. Relatives more than 55 years old were excluded to avoid bias in answering the questions due to cognitive decline. Those who had acute mental illness at the time of assessment or were not willing to give informed consent were also excluded from the study. Participants were explained about the study and were assessed by a single interviewer in a single setting with respect to the above-mentioned measures. Around 30 min was spent by a participant in the assessment.

Statistical analysis

Appropriate statistical software, including MS Excel and PSPP version 0.8.5, was used for statistical analysis. Descriptive statistics were used to analyze the sociodemographic and illness-related variables. Association between qualitative variables was assessed by the Chi-square test, with continuity correction for all 2 × 2 tables and by Fisher's exact test for all 2 × 2 tables where the Chi-square test was not valid due to small counts. Comparison of ordinal data between qualitative variable with three or more subgroups was assessed using the Kruskal–Wallis test. Comparison of ordinal data between qualitative variable with two sub-groups was assessed using the Mann–Whitney test.

P < 0.05 was considered as statistically significant for the purpose of the study.

RESULTS

Sociodemographic profile

There were 75 males and 75 females in the study. Sixty-two of 150 relatives (41.33%) had studied beyond matriculation. One hundred participants (67%) were working at the time of assessment, and 112 participants (74.67%) belonged to middle socioeconomic status. Ninety-six of 150 participants (64%) were staying in a nuclear family setup.

Illness-related variables

Ten relatives (7%) had a psychiatric illness at the time of assessment. Five of them were suffering from schizophrenia, and the other five had depression. All 10 of them were taking treatment for their illness and were well maintained on treatment at the time of assessment.

Symptom checklist 90 revised

Data on SCL 90R were analyzed using descriptive statistics. Eighty-two of 150 (54.67%) had a significant score on SCL 90R. Among them, 48 participants (58.5%) had either somatization or depression. [Table 1]

Table 1

Inference on symptom checklist 90 revised for relatives having a significant score

SCL 90R subscale	n (%)
1 Somatization	27 (32.9)
2 Depression	21 (25.6)
3 Anger hostility	8 (9.8)
4 Obsessive compulsive	8 (9.8)
5 Interpersonal sensitivity	6 (7.3)
6 Paranoia	6 (7.3)
7 Anxiety	4 (4.9)
8 Phobic anxiety	2 (2.4)
9 Psychoticism	0
Total	82 (100)

SCL 90R – Symptoms checklist 90 revised

Big five inventory

Data on BFI were analyzed using descriptive statistics. [Table 2]

Table 2

Description of the Big Five inventory for the study sample

BFI dimension	Mean (SD)	Range
Extraversion	24.99 (4.55)	8-40 (8 items on BFI)
Agreeableness	33.97 (6.51)	9-45 (9 items on BFI)
Conscientiousness	33.55 (6.62)	9-45 (9 items on BFI)
Neuroticism	21.84 (4.62)	8-40 (8 items on BFI)
Openness	29.88 (6.13)	10-50 (10 items on BFI)

SD – Standard deviation; BFI – Big Five inventory

Relation between psychopathology and personality factors

Those relatives who had significant psychopathology scored higher on neuroticism and lower on agreeableness domains. This difference was statistically significant. [Table 3]

Table 3

Comparison of big five personality factors with psychopathology on symptom checklist 90 revised

Variables	SCL 90R status	n	Mean (SD)	Z	P
Score on BFI extraversion	Significant	82	24.94 (3.84)	−0.758	0.448
	Not significant	68	25.06 (5.32)	Difference is not significant
Score on BFI agreeableness	Significant	82	33.32 (5.40)	−2.182	0.029*
	Not significant	68	34.75 (7.61)	Difference is significant
Score on BFI conscientiousness	Significant	82	33.13 (6.08)	−1.605	0.109
	Not significant	68	34.04 (7.23)	Difference is not significant
Score on BFI neuroticism	Significant	82	23.21 (4.03)	−3.574	3.51E-04**
	Not significant	68	20.19 (4.76)	Difference is significant
Score on BFI openness	Significant	82	30.23 (5.21)	−0.308	0.758
	Not significant	68	29.46 (7.10)	Difference is not significant

*P<0.05, **P<0.001. SD – Standard deviation; BFI – Big Five inventory; SCL 90R – Symptoms checklist 90 revised

DISCUSSION

54.67% of first-degree relatives (82 of 150 had significant psychopathology on SCL 90R. Among them, 42 (58.5%) had either somatization or depression. Nearly 7%–10% of relatives scored higher on each of the anger hostility, obsessive-compulsive, interpersonal sensitivity, and paranoia subscales. Ten of 150 (6.67%) were already a known case of mental illness at the time of assessment. Similar findings were observed by Arajärvi et al., where they studied 183 siblings of patients with schizophrenia and found that 54% of them had a lifetime diagnosis of a mental disorder.[12] They also found that 7.7% of the study sample already had psychotic symptoms at the time of assessment.[12]

Schizophrenia aggregates in families and evidence suggest that familial risk for mental illnesses might be broader with an increased risk for schizoaffective disorder, paranoid disorder, atypical psychosis, depression, and substance dependence.[4671314] Such risks are supported by twin and molecular genetic studies which show that genetic dispositions to mood disorders and schizophrenia overlap.[151617]

On comparing psychopathology and personality factors, it was found that relatives who had psychopathology had a significant difference in two domains of BFI. They scored significantly higher on neuroticism and lower on agreeableness domains. The Big Five dimension of agreeableness is the tendency to be friendly, compassionate, and cooperative.[1819] Neuroticism is the tendency to experience negative emotions such as irritability and insecurity.[19] Neuroticism has been found to be a robust predictor of psychopathology.[2021] People high in neuroticism react to stressful situations with high levels of distress, anxiety, and worry providing an increased risk for various forms of psychopathology, particularly mood and anxiety disorders.[202122] Their frequent expressions of worry lead to negative reactions from others and also contribute to poor decision-making, thereby reinforcing the original stress.[202122] A higher score on neuroticism may have contributed to significant psychopathology, especially somatization and depression in the present study. Somatization may be viewed as “masked depression,” where people present with somatic symptoms and have psychological symptoms in the background.[23]

First-degree relatives of schizophrenic probands score higher on schizotypal, paranoid, and schizoid personality traits as compared to normal controls.[242526] These cluster A personality traits are characterized by social and interpersonal deficits, lack of close friends, and negative emotions such as suspiciousness toward others, magical thinking, and flattened affectivity.[7] This, in turn, could have led to higher scores on neuroticism and lower scores on agreeableness in the present study.

CONCLUSION

More than 50% relatives had a significant psychopathology, most common psychopathology found was somatization and depression. Those having psychopathology scored significantly higher on Neuroticism and lower on Agreeableness domains of Big Five personality factors. Thus relatives of patients with schizophrenia should be regularly screened for presence of psychopathology. Also a relation between psychopathology and personality factors was observed though how exactly one factor influences the other could not be established.

Limitations

SCL 90R is a screening tool and not a diagnostic measure of psychopathology.

Future directions

Longitudinal studies looking into the relationship between psychopathology and personality may be beneficial in finding how one influences the other.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.