Expressed emotion refers to the emotional environment of psychiatric patients as measured by their family/caregivers' attitudes and statements. High expressed emotion, characterized by criticism, hostility, and overinvolvement, is linked to higher relapse rates in patients. Researchers developed tools like the Camberwell Family Interview and Five-Minute Speech Sample to assess expressed emotion by analyzing family interviews. High levels may relate to stress models of mental illness, with family environment contributing to patients' stress levels. However, expressed emotion may vary across cultures and most studies are limited to Western cultures.
Expressed emotion refers to the emotional environment of psychiatric patients as measured by their family/caregivers' attitudes and statements. High expressed emotion, characterized by criticism, hostility, and overinvolvement, is linked to higher relapse rates in patients. Researchers developed tools like the Camberwell Family Interview and Five-Minute Speech Sample to assess expressed emotion by analyzing family interviews. High levels may relate to stress models of mental illness, with family environment contributing to patients' stress levels. However, expressed emotion may vary across cultures and most studies are limited to Western cultures.
Expressed emotion refers to the emotional environment of psychiatric patients as measured by their family/caregivers' attitudes and statements. High expressed emotion, characterized by criticism, hostility, and overinvolvement, is linked to higher relapse rates in patients. Researchers developed tools like the Camberwell Family Interview and Five-Minute Speech Sample to assess expressed emotion by analyzing family interviews. High levels may relate to stress models of mental illness, with family environment contributing to patients' stress levels. However, expressed emotion may vary across cultures and most studies are limited to Western cultures.
To understand the origins of the concept of “expressed emotion” (EE), one must go back to the 1950’s, to the seminal work of George Brown. To understand the basis for symptom relapse soon after release from long term treatment, a study was initiated by George Brown and his colleagues with 229 men discharged from psychiatric hospitals, 156 of them with a diagnosis of schizophrenia (as cited in Leff, 2000). From the study, it was observed that the strongest link with relapse and readmission was the type of home to which patients were discharged. They observed that the relapse rate in patients who went home to critical, over-involved, or hostile families was more than double that of patients from other types of families. This effect was more pronounced if patients spent more than 35 hours a week in close contact with their families. Although this observation matched with clinical experience, it was not universally welcomed. Most of the objections came from families who did not like being labeled as high expressed emotion; they felt they were being blamed for the patient’s illness. Another argument against the concept was that the effect of EE on relapse was not of the same magnitude as that of medication or other variables, and thus was not to be taken into account. But despite these reservations, the evidence for a relation between EE and relapse remains strong (The Lancet, 1992). The components of expressed emotion George Brown explained five components of EE which includes critical comments, hostility, emotional over-involvement, positive remarks, and warmth (as cited in Wearden, Tarrier, Barrowclough, Zastowny, & Rahill, 2000). The quantification of critical comments and hostility is greatly reliant on the way in which the respondent uses their tone of voice to convey their feelings (anger, rejection, irritability, ignorance, blaming, negligence etc.), while the judgment of over-involvement takes into account reported behavior such as caregivers blaming themselves, sacrificing things, being overprotective of patients, excessively being concerned for patients, neglecting own personal needs, and similar others. Venkatasubramanian & Amaresha (2012) explain: 1. Critical comments: Patients who are unable to get up in the morning, who fail to wash regularly, or who do not participate in household tasks etc., are criticized for being lazy and selfish; unfortunately, in this context, the caregivers fail to understand that these could be potential manifestations of negative symptoms of schizophrenia or any other psychotic disorder. By contrast, low EE caregivers are more capable of recognizing aspects of the patient’s behavior which are a manifestation of the illness. (For example: Family caregivers may express in increased tone, tempo, or volume that the patient frustrates them and deliberately causes problems for them; that family members feel the burden of managing the patient’s needs and that living with him/her is hard; or even commenting that patient is ignoring or not following their advice which is why the illness continues). 2. Hostility: It is a consequence of anger and irritation towards the patient. Hostility is expressed by general criticisms or attitudes that accuse, reject or demean the patient. (For example: Caregivers state that the patient intentionally causes problems for them, wish aloud to live away from the patient, shouts at the patient, accuse the patient of being able to control himself but acting as though not). 3. Emotional overinvolvement (EOI): Manifests itself by over-emotionality, excessive self-sacrifice, over-identification, and extremely overprotective behavior with the patient. Parents of children, who develop schizophrenia, oftentimes feel guilty for the child’s illness. This chronic guilt leads them to initiate excessive reparative efforts to make things better for the child. Unfortunately, this has the effect of discouraging the person’s skills and self-reliance, so that in the long run, overprotectiveness hampers the person’s recovery. It also leads to dependence of the patient on their caregiver. (For example: Caregivers blame themselves for everything that goes wrong and feels like everything is their fault; does not allow or encourage the patient to carry out his/her day-to-day activities by themselves; gives less importance to personal needs than patient needs). 4. Warmth: Is expressed through kindness, concern, and empathy of the caregiver. It depends greatly on vocal qualities of speech, with smiling and positive verbalizations being common accompaniments, which often conveys an empathic attitude by the relative. Warmth is a significant characteristic of the low EE family. (For example: Caregivers state that patient tries to get along with everyone, makes a lot of sense, is easy to get along with, and is good to have around, etc). 5. Positive regard: This comprises of statements that express appreciation or support for patient’s behavior and verbal/nonverbal reinforcement by the caregiver. (For example: Family states that they feel very close to the patient, they appreciate patient’s little efforts in his day-to-day functioning, state that they can cope with the patient and enjoy being with him/her). Assessment of expressed emotion EE measures the attitudes, quality of relationships and interaction patterns among psychiatric patients and their close family members. There are many instruments which assess the family environment in terms of EE. Some of these important EE assessment tools are: 1. Camberwell Family Interview (CFI): During the interview, relative’s speech is recorded and later used for coding. This semi-structured interview consists of questions which address the onset of the patient’s illness and the symptoms that were noticeable to the relative in the months earlier to the patient’s worsening of illness or admission to the hospital; which provides an understanding about relative’s involvement as well as attitudes toward the patient. 2. The Five-Minute Speech Sample (FMSS): The five-minute speech sample (FMSS) is similar to the CFI in that family members talk about their patient and their relationship for five uninterrupted minutes and the speech is recorded and later coded for the overall level of EE, criticism, and EOI. 3. Level of expressed emotion scale (LEE scale): This is a 60-item, self-report scale that measures the emotional environment in the patient’s most important relationships. It has 60 items that form the four subscales, namely Intrusiveness, Emotional Response, Attitude toward Illness, and Tolerance and Expectations. Items are rated in a true– false format. 4. Perceived criticism scale (PCS): This scale recognizes that the most important element of EE is criticism. It consists of only one question, namely “How critical do you consider your relative to be of you?” It is administered as a 10-point Likert-type scale and anchored with values between “not at all critical” and “very critical indeed.” 5. Family emotional involvement and criticism scale (FEIC scale): It is a 14-item scale which assesses two dimensions of EE: EOI and perceived criticism (PC) in the family. 6. Family attitude scale: It is a 30-item, self-report measure of EE which emphasizes on criticism and hostility. Respondents report how often each statement is true on a scale ranging from “Everyday” (4) to “Never” (0). Models of expressed emotion Locus of control model: Studies show that locus of control and EE has significant associations, especially with an internal locus of control. High EE caregivers, particularly those who are high in criticality, have been shown to have a more internally based locus of control than do low EE caregivers and to be more self-blaming. It was also found that highly critical caregivers are more likely than low critical caregivers to have an internal locus of control (Hooley, 1998). Stress-diathesis model or the stress-vulnerability model (Zubin & Spring, 1977): In this model, the degree of vulnerability to a given psychiatric episode is determined by each person’s tolerance to traumatic or stressful life events. As EE appears to accurately determine relapse among patients, the research suggested that family environment may be a major contributing factor to critical stress levels among persons with schizophrenia. Stress-diathesis approach facilitates the view that both patients and caregivers are involved in a system of mutual influence in which each contributes to the stress that acts on the intrinsic vulnerabilities of the other; this perspective emphasizes upon interactions between vulnerability and stress variables. Considerable research data on EE with regard to illness relapse also shows EE as a form of psychosocial stress. Cultural variables Most of the studies that contribute to our understanding of EE are largely from Western countries, all of them cross-sectional, and problems regarding the cross-cultural validity of assessments of EE are not usually discussed. The cross-cultural validity of EE has been examined in a few non-Western cultures, with controversial findings (Cheng, 2002). The frequency and intensity of individual types of EE vary widely across cultures, with the proportion of high EE among relatives of individuals with schizophrenia defined by the Western operational criteria ranging from 8% in rural India (Wig et.al, 1987b) to 67% in urban USA (Vaughn et.al, 1984). The finding that a very low proportion (4%) of the relatives of people with schizophrenia in the Indian study was rated high in emotional over-involvement was attributed to issues of inter-rater reliability resulting from training problems (Wig et.al, 1987a). A corresponding figure of 7.0% was reported in China (Phillips & Xiong, 1995). The authors commented that the Western criteria for high emotional over-involvement are inappropriate in Asian culture, where most unmarried persons with schizophrenia stay with their parents. This may bring about much more contact between patients and their parents, leading to greater exposure to EE in Chinese and other non-Western societies than in their Western counterparts. It is known that Asian families are parent-child dominated, rather than husband-wife dominated as observed in Western societies (Hsu, 1973). Unlike the Western family, in which the autonomy and independence of children are stressed, in the Asian family children's obedience and acceptance of parents' criticism, and interdependence between generations, are encouraged. The implications of such differential exposure to EE may deserve further inquiry (Cheng, 2002). Psychosocial intervention to reduce expressed emotion Family-focused psychosocial interventions primarily emphasize on reducing the levels of EE of caregivers by enhancing their knowledge about the illness. Family psychoeducation (FP) aims at reducing re-hospitalization by controlling the relapse of symptoms and helping patient adhere to the treatment, and it also aims to reduce the distress faced by family caregivers and improve patient-family relations and communication patterns. FP includes education to the patient and caregiver about illness, crisis management, problem-solving skills, clarifying myths and misconceptions, and emotional support. The length and duration of the intervention vary across the cultures. It depends upon the person’s socioeconomic, education, and domicile status (Venkatasubramanian & Amaresha, 2012). Conclusion Caring for a person with schizophrenia is highly challenging, and it might result in a negative emotional atmosphere in the patient’s family which can cause not only relapse of symptoms and re-hospitalization, but significantly affect the course of the illness. The symptoms displayed by the patient influence the caregiver’s EE and this, in turn, influences symptom relapse in patients. Hence, treatment should attempt at a holistic, multidisciplinary, bio- psychosocial approach which addresses all dimensions of the patient and his/her family environment. References Cheng, A. T. (2002). Expressed emotion: a cross-culturally valid concept? The British Journal of Psychiatry, 181(6), 466-467. doi:10.1192/bjp.181.6.466 Expressed emotion in schizophrenia. (1992). The Lancet, 340(8826), 1007-1008. doi:10.1016/0140-6736(92)93014-e Hsu, F. L. K. (1973) Kinship is the key. The Center Magazine, 11(6), 4 -14. Hooley, J. M. (1998). Expressed Emotion and Locus of Control. The Journal of Nervous & Mental Disease, 186(6), 374-378. doi:10.1097/00005053-199806000-00009 Leff J. (2000) Expressed emotion: Measuring relationships. In: Harris T, editor. Where inner and outer worlds meet: Psychosocial research in the tradition of George W Brown. 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