Expressed emotion

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Expressed emotion (EE), is a measure of the family environment that is based on how the relatives of a psychiatric patient spontaneously talk about the patient. [1] It specifically measures three to five aspects of the family environment: the most important are critical comments, hostility, emotional over-involvement, with positivity and warmth sometimes also included as indications of a low-EE environment. [2] The psychiatric measure of expressed emotion is distinct from the general notion of communicating emotion in interpersonal relationships, and from another psychological metric known as family emotional expressiveness. [3]

Contents

A high level of EE in the home can worsen the prognosis in patients with mental illness, such as schizophrenia and social anxiety disorder, [4] [5] or act as a potential risk factor for the development of psychiatric disease. [6] Higher degrees of expressed emotion in the environment of a patient have been empirically found to be robust predictors of relapse of schizophrenia, eating disorder, and mood disorders. [1] [2] It has also been investigated as a contributor to the progress of unipolar depression, bipolar disorder, dementia, and diabetes. [1] Interventions to improve outcomes include reducing contact with high-EE caregivers, and educating and supporting families so they can reduce high-EE behavior. [2]

Various mechanisms have been proposed to explain why high EE family environments produce worse outcomes, including that: [2]

Typically it is determined whether a person or family has high EE or low EE through a taped interview known as the Camberwell Family Interview (CFI). Answers to questions and non-verbal cues are used to determine if someone has high expressed emotion. There is another measurement that is taken from the view of the patient, which rates the patient's perception of how their family feels about them and the disorder. An alternative measure of expressed emotion is the Five Minutes Speech Sample (FMSS), where the relatives are asked to talk about the patient for five uninterrupted minutes. Although this measure requires more training, it becomes a quicker form of assessment than the CFI. [7]

History

A 1956 study of readmissions of schizophrenia patients in London by George Brown found that patients discharged to live with their parents or wives were more frequently readmitted than those discharged to live with siblings or non-family in lodging houses. It also found that those that lived with their mothers were more likely to be readmitted if the mothers did not work outside the home, suggesting that the duration of exposure to certain family members was related to relapse. [2] Brown devised the five dimensions of expressed emotion to quantify the interpersonal environmental exposures of patients. [2]

The advantage of a low-EE environment has been cited to partly explain the success of the Belgian village of Geel, where residents have for hundreds of years welcomed unrelated people with mental illness to live with them. [8]

Janis H. Jenkins and her team conducted the first study showing that Mexican immigrants’ familial emotional responses of warmth and sympathy toward mentally ill kin in the United States contributes to a more favorable course of illness than in the case of their Euro-American counterparts. [9]

High expressed emotion

Family members with high expressed emotion are hostile, very critical and not tolerant of the patient. They feel like they are helping by having this attitude. They not only criticize behaviors relating to the disorder but also other behaviors that are unique to the personality of the patient. High expressed emotion is more likely to cause a relapse than low expressed emotion.

The three dimensions of high EE are hostility, emotional over-involvement and critical comments.

Hostility

Hostility is a negative attitude directed at the patient because the family feels that the disorder is controllable and that the patient is choosing not to get better. Problems in the family are often blamed on the patient and the patient has trouble problem solving in the family. The family believes that the cause of many of the family's problems is the patient's mental illness, whether they are or not.

Emotional over-involvement

Emotional over-involvement reflects a set of feelings and behavior of a family member towards the patient, indicating evidence of over-protectiveness or self-sacrifice, excessive use of praise or blame, preconceptions and statements of attitude. Family members who show high emotional involvement tend to be more intrusive. Therefore, families with high emotional involvement may believe that patients cannot help themselves and that their problems are due to causes external to them, and thus high involvement will lead to strategies of taking control and doing things for the patients. In addition, patients may feel very anxious and frustrated when interacting with family caregivers with high emotional involvement due to such high intrusiveness and emotional display towards them. On the whole, families with high EE appear to be poorer communicators with their ill relative as they might talk more and listen less effectively. Emotional over-involvement demonstrates a different side compared to hostile and critical attitudes but is still similar with the negative affect that causes a relapse. The relative becomes so overbearing that the patient can no longer live with this kind of stress from pity, and falls back into their illness as a way to cope. [10]

Critical comments

Critical comments include complaints that the patient is a burden to the family, that the patient is not following instructions, or that the patient is lazy or selfish. [2]

Interventions

Low expressed emotion occurs when the family members are less critical or hostile, and not overly-involved. Low expressed emotion is associated with more positive outcomes for the patient. Psychoeducation on the course and associated effects of the illness, as well as behavioral interventions and communication training can help families move from high expressed emotion to low expressed emotion. However, it is believed that in the early stages of the illness, families should be allowed to grieve and be supported emotionally, and that behavioral interventions can actually increase relapse rates at this critical juncture. [11]

High expressed emotion, by contrast, makes the patient feel trapped, out of control and dependent upon others. The patient may feel like an outsider because of the excessive attention received. Expressed emotion affects everyone in the home, raising the stress level for the family and often increasing anxiety and depression among family members. [11] The behavior of everyone around the patient influences the course of the patient's illness. Academics suggest that movement from high to low expressed emotion is best facilitated by a family therapist, psychiatrist, or family worker, preferably one experienced in the treatment of families with a psychotic family member. [11] Family therapists suggest that treatment is more successful with the attendance of as many household members as possible, in order to give a more complete picture of family patterns. However, the necessity of family therapy does not indicate that the illness is the fault of the family. Family therapy in this area has moved away from the notion that family communication patterns are responsible for psychosis, a notion popularized in the 1960s by family systems therapist Murray Bowen. [12]

Validity

Some studies show that there is no link between expressed emotion and first episode psychosis, illness severity, age of onset, and illness length. [13]

There is also literature that links EE to the course and outcome of numerous major childhood psychiatric disorders. One study [14] showed that one component, high parental dimensions of criticism (CRIT), can be used as an index of problematic parent–child interactions.

In social anxiety disorder, it has been found parents' high level of expressed emotion (emotional overinvolvement, criticism, hostility) is strongly associated with treatment outcome in their children. [15]

See also

Related Research Articles

A mental disorder, also referred to as a mental illness, a mental health condition, or a psychiatric disability, is a behavioral or mental pattern that causes significant distress or impairment of personal functioning. A mental disorder is also characterized by a clinically significant disturbance in an individual's cognition, emotional regulation, or behavior, often in a social context. Such disturbances may occur as single episodes, may be persistent, or may be relapsing–remitting. There are many different types of mental disorders, with signs and symptoms that vary widely between specific disorders. A mental disorder is one aspect of mental health.

Psychosis is a condition of the mind or psyche that results in difficulties determining what is real and what is not real. Symptoms may include delusions and hallucinations, among other features. Additional symptoms are incoherent speech and behavior that is inappropriate for a given situation. There may also be sleep problems, social withdrawal, lack of motivation, and difficulties carrying out daily activities. Psychosis can have serious adverse outcomes.

<span class="mw-page-title-main">Schizophrenia</span> Mental disorder with psychotic symptoms

Schizophrenia is a mental disorder characterized by hallucinations, delusions, disorganized thinking and behavior, and flat or inappropriate affect. Symptoms develop gradually and typically begin during young adulthood and are never resolved. There is no objective diagnostic test; diagnosis is based on observed behavior, a psychiatric history that includes the person's reported experiences, and reports of others familiar with the person. For a diagnosis of schizophrenia, the described symptoms need to have been present for at least six months or one month. Many people with schizophrenia have other mental disorders, especially depressive disorder, anxiety disorders, and obsessive–compulsive disorder.

<span class="mw-page-title-main">Borderline personality disorder</span> Personality disorder of emotional instability

Borderline personality disorder (BPD), also known as emotionally unstable personality disorder (EUPD), is a personality disorder characterized by a pervasive, long-term pattern of significant interpersonal relationship instability, a distorted sense of self, and intense emotional responses. Individuals diagnosed with BPD frequently exhibit self-harming behaviours and engage in risky activities, primarily due to challenges regulating emotional states to a healthy, stable baseline. Symptoms such as dissociation, a pervasive sense of emptiness, and an acute fear of abandonment are prevalent among those affected.

The topic and directed area of focus for this section is Psychopathology. Psychopathology is the studied idea of varies thoughts, behaviors, and emotions expressed. These three are expressed very differently throughout each individual. Psychiatric disability can be developed from an altered behavior, emotion, or thought. Some of the major sections included within the article are read as supernatural and psychological explanations as well as a range of many other mental disorders listed and described in the latter portion of the article. Psychopathology is a heavily researched and studied area in the field of psychology.

Schizoaffective disorder is a mental disorder characterized by abnormal thought processes and an unstable mood. This diagnosis requires symptoms of both schizophrenia (psychosis) and a mood disorder: either bipolar disorder or depression. The main criterion is the presence of psychotic symptoms for at least two weeks without any mood symptoms. Schizoaffective disorder can often be misdiagnosed when the correct diagnosis may be psychotic depression, bipolar I disorder, schizophreniform disorder, or schizophrenia. This is a problem as treatment and prognosis differ greatly for most of these diagnoses. Many people with schizoaffective disorder have other mental disorder including anxiety disorders.

<span class="mw-page-title-main">Anhedonia</span> Inability to feel pleasure

Anhedonia is a diverse array of deficits in hedonic function, including reduced motivation or ability to experience pleasure. While earlier definitions emphasized the inability to experience pleasure, anhedonia is currently used by researchers to refer to reduced motivation, reduced anticipatory pleasure (wanting), reduced consummatory pleasure (liking), and deficits in reinforcement learning. In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), anhedonia is a component of depressive disorders, substance-related disorders, psychotic disorders, and personality disorders, where it is defined by either a reduced ability to experience pleasure, or a diminished interest in engaging in previously pleasurable activities. While the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) does not explicitly mention anhedonia, the depressive symptom analogous to anhedonia as described in the DSM-5 is a loss of interest or pleasure.

<span class="mw-page-title-main">Creativity and mental health</span> Concept in psychology

Links between creativity and mental health have been extensively discussed and studied by psychologists and other researchers for centuries. Parallels can be drawn to connect creativity to major mental disorders including bipolar disorder, autism, schizophrenia, major depressive disorder, anxiety disorder, OCD and ADHD. For example, studies have demonstrated correlations between creative occupations and people living with mental illness. There are cases that support the idea that mental illness can aid in creativity, but it is also generally agreed that mental illness does not have to be present for creativity to exist.

Thought broadcasting is a type of delusional condition in which the affected person believes that others can hear their inner thoughts, despite a clear lack of evidence. The person may believe that either those nearby can perceive their thoughts or that they are being transmitted via mediums such as television, radio or the internet. Different people can experience thought broadcasting in different ways. Thought broadcasting is most commonly found among people who have a psychotic disorder, specifically schizophrenia.

Schizophreniform disorder is a mental disorder diagnosed when symptoms of schizophrenia are present for a significant portion of time, but signs of disturbance are not present for the full six months required for the diagnosis of schizophrenia.

Psychoeducation is an evidence-based therapeutic intervention for patients and their loved ones that provides information and support to better understand and cope with illness. Psychoeducation is most often associated with serious mental illness, including dementia, schizophrenia, clinical depression, anxiety disorders, eating disorders, bipolar and personality disorders. The term has also been used for programs that address physical illnesses, such as cancer.

Dual diagnosis is the condition of having a mental illness and a comorbid substance use disorder. There is considerable debate surrounding the appropriateness of using a single category for a heterogeneous group of individuals with complex needs and a varied range of problems. The concept can be used broadly, for example depression and alcohol use disorder, or it can be restricted to specify severe mental illness and substance use disorder, or a person who has a milder mental illness and a drug dependency, such as panic disorder or generalized anxiety disorder and is dependent on opioids. Diagnosing a primary psychiatric illness in people who use substances is challenging as substance use disorder itself often induces psychiatric symptoms, thus making it necessary to differentiate between substance induced and pre-existing mental illness.

<span class="mw-page-title-main">Grandiose delusions</span> Subtype of delusion

Grandiose delusions (GDs), also known as delusions of grandeur or expansive delusions, are a subtype of delusion characterized by extraordinary belief that one is famous, omnipotent, wealthy, or otherwise very powerful. Grandiose delusions often have a religious, science fictional, or supernatural theme. Examples include the extraordinary belief that one is a deity or celebrity, or that one possesses extraordinary talents, accomplishments, or superpowers.

Brief psychotic disorder—according to the classifications of mental disorders DSM-IV-TR and DSM-5—is a psychotic condition involving the sudden onset of at least one psychotic symptom lasting 1 day to 1 month, often accompanied by emotional turmoil. Remission of all symptoms is complete with patients returning to the previous level of functioning. It may follow a period of extreme stress including the loss of a loved one. Most patients with this condition under DSM-5 would be classified as having acute and transient psychotic disorders under ICD-10. Prior to DSM-IV, this condition was called "brief reactive psychosis." This condition may or may not be recurrent, and it should not be caused by another condition.

Supportive psychotherapy is a psychotherapeutic approach that integrates various therapeutic schools such as psychodynamic and cognitive-behavioral, as well as interpersonal conceptual models and techniques.

Folie à deux, also known as shared psychosis or shared delusional disorder (SDD), is a psychiatric syndrome in which symptoms of a delusional belief are "transmitted" from one individual to another.

<span class="mw-page-title-main">Persecutory delusion</span> Delusion involving perception of persecution

A persecutory delusion is a type of delusional condition in which the affected person believes that harm is going to occur to oneself by a persecutor, despite a clear lack of evidence. The person may believe that they are being targeted by an individual or a group of people. Persecution delusions are very diverse in terms of content and vary from the possible, although improbable, to the completely bizarre. The delusion can be found in various disorders, being more usual in psychotic disorders.

<span class="mw-page-title-main">Prognosis of schizophrenia</span>

The prognosis of schizophrenia is varied at the individual level. In general it has great human and economics costs. It results in a decreased life expectancy of 12–15 years primarily due to its association with obesity, little exercise, and smoking, while an increased rate of suicide plays a lesser role. These differences in life expectancy increased between the 1970s and 1990s, and between the 1990s and 2000s. This difference has not substantially changed in Finland for example – where there is a health system with open access to care.

Pseudoneurotic schizophrenia is a postulated mental disorder categorized by the presence of two or more symptoms of mental illness such as anxiety, hysteria, and phobic or obsessive-compulsive neuroses. It is often acknowledged as a personality disorder. Patients generally display salient anxiety symptoms that disguise an underlying psychotic disorder.

The outcomes paradox is the observation that patients with schizophrenia in developing countries benefit much more from therapy than those in developed countries. This is surprising because the reverse holds for most diseases: "the richer and more developed the country, the better the patient outcome." The outcomes paradox came to light in the 1960s due to cross-cultural studies conducted by the World Health Organization on the outcome of severe mental disorders like schizophrenia. This paradox has become an axiom in international psychiatry since.

References

  1. 1 2 3 Butzlaff RL, Hooley JM (June 1998). "Expressed emotion and psychiatric relapse: a meta-analysis". Arch. Gen. Psychiatry. 55 (6): 547–52. doi: 10.1001/archpsyc.55.6.547 . PMID   9633674.
  2. 1 2 3 4 5 6 7 Venkatasubramanian, Ganesan; Amaresha, AnekalC (2012-01-01). "Expressed Emotion in Schizophrenia: An Overview". Indian Journal of Psychological Medicine. 34 (1): 12–20. doi: 10.4103/0253-7176.96149 . PMC   3361836 . PMID   22661801.
  3. ↑ Family emotional expressiveness and family structure
  4. ↑ Brown G, Birley J, Wing J (1972). "Influence of family life on the course of schizophrenic disorder: a replication". British Journal of Psychiatry. 121 (562): 241–258. doi:10.1192/bjp.121.3.241. PMID   5073778. S2CID   40443476.
  5. ↑ Garcia-Lopez LJ, Muela JAE-F, Diaz-Castela MM (2009). "Exploring the relevance of expressed emotion to the treatment of social anxiety disorder in adolescence". Journal of Adolescence. 32 (6): 1371–1376. doi:10.1016/j.adolescence.2009.08.001. PMID   19762073.
  6. ↑ Asarnow JR, Tompson M, Woo S, Cantwell DP (December 2001). "Is expressed emotion a specific risk factor for depression or a nonspecific correlate of psychopathology?". J Abnorm Child Psychol. 29 (6): 573–83. doi:10.1023/A:1012237411007. PMID   11761289. S2CID   22980727.
  7. ↑ Hooley JM (2007). "Expressed emotion and relapse of psychopathology". Annu Rev Clin Psychol. 3: 329–52. doi:10.1146/annurev.clinpsy.2.022305.095236. PMID   17716059.
  8. ↑ The Problem with the Solution (transcript) - Invisibilia podcast, 1 July 2016
  9. ↑ Bhugra, Dinesh; McKenzie, Kwame (September 2003). "Expressed emotion across cultures". Advances in Psychiatric Treatment. 9 (5): 342–348. doi:10.1192/apt.9.5.342.
  10. ↑ Mohapatra D. "Expressed Emotion in Psychiatric Disorders: A Review". Academia.
  11. 1 2 3 Addington, J.; Jones, B. (2001). Family intervention in early psychosis. Psychiatr. Rehabil. Skills. pp. 272–286. Retrieved 29 February 2020.
  12. ↑ Bowen, M. (1960). A Family Concept of Schizophrenia. Oxford: Basic Books. pp. 346–372. doi:10.1037/10605-012.
  13. ↑ Raune D, Kuipers E, Bebbington PE (April 2004). "Expressed emotion at first-episode psychosis: investigating a carer appraisal model". Br J Psychiatry. 184 (4): 321–6. doi: 10.1192/bjp.184.4.321 . PMID   15056576.
  14. ↑ McCarty CA, Lau AS, Valeri SM, Weisz JR (February 2004). "Parent-child interactions in relation to critical and emotionally overinvolved expressed emotion (EE): is EE a proxy for behavior?". J Abnorm Child Psychol. 32 (1): 83–93. doi:10.1023/b:jacp.0000007582.61879.6f. PMC   1352329 . PMID   14998113.
  15. ↑ Garcia-Lopez, LJ; et al. (2014). "Can parent training for parents with high levels of expressed emotion have a positive effect on their child's social anxiety improvement?". Journal of Anxiety Disorders. 28 (8): 812–822. doi: 10.1016/j.janxdis.2014.09.001 . PMID   25265549.

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