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.
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.
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
Family (from la, familia) is a Social group, group of people related either by consanguinity (by recognized birth) or Affinity (law), affinity (by marriage or other relationship). The purpose of the family is to maintain the well-being of its ...
.
A high level of EE in the home can worsen the
prognosis
Prognosis (Greek: πρόγνωσις "fore-knowing, foreseeing") is a medical term for predicting the likely or expected development of a disease, including whether the signs and symptoms will improve or worsen (and how quickly) or remain stabl ...
in patients with
mental illness
A mental disorder, also referred to as a mental illness or psychiatric disorder, is a behavioral or mental pattern that causes significant distress or impairment of personal functioning. Such features may be persistent, relapsing and remitti ...
, such as
schizophrenia
Schizophrenia is a mental disorder characterized by continuous or relapsing episodes of psychosis. Major symptoms include hallucinations (typically hearing voices), delusions, and disorganized thinking. Other symptoms include social withdra ...
and
social anxiety disorder
Social anxiety disorder (SAD), also known as social phobia, is an anxiety disorder characterized by sentiments of fear and anxiety in social situations, causing considerable distress and impaired ability to function in at least some aspects ...
, or act as a potential
risk factor
In epidemiology, a risk factor or determinant is a variable associated with an increased risk of disease or infection.
Due to a lack of harmonization across disciplines, determinant, in its more widely accepted scientific meaning, is often use ...
for the development of psychiatric disease. Higher degrees of expressed emotion in the environment of a patient have been empirically found to be robust predictors of relapse of
schizophrenia
Schizophrenia is a mental disorder characterized by continuous or relapsing episodes of psychosis. Major symptoms include hallucinations (typically hearing voices), delusions, and disorganized thinking. Other symptoms include social withdra ...
,
eating disorder
An eating disorder is a mental disorder defined by abnormal eating behaviors that negatively affect a person's physical or mental health. Only one eating disorder can be diagnosed at a given time. Types of eating disorders include binge eating d ...
, and
mood disorders
A mood disorder, also known as an affective disorder, is any of a group of conditions of mental and behavioral disorder where a disturbance in the person's mood is the main underlying feature. The classification is in the ''Diagnostic and Stat ...
.
It has also been investigated as a contributor to the progress of
unipolar depression
Major depressive disorder (MDD), also known as clinical depression, is a mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities. Introdu ...
,
bipolar disorder
Bipolar disorder, previously known as manic depression, is a mental disorder characterized by periods of depression and periods of abnormally elevated mood that last from days to weeks each. If the elevated mood is severe or associated with ...
,
dementia
Dementia is a disorder which manifests as a set of related symptoms, which usually surfaces when the brain is damaged by injury or disease. The symptoms involve progressive impairments in memory, thinking, and behavior, which negatively affe ...
, and
diabetes
Diabetes, also known as diabetes mellitus, is a group of metabolic disorders characterized by a high blood sugar level ( hyperglycemia) over a prolonged period of time. Symptoms often include frequent urination, increased thirst and increased ap ...
.
Interventions to improve outcomes include reducing contact with high-EE caregivers, and educating and supporting families so they can reduce high-EE behavior.
Various mechanisms have been proposed to explain why high EE family environments produce worse outcomes, including that:
* Critical comments often misidentify certain behaviors as laziness or selfishness rather than symptoms of a mental illness.
* Over-protectiveness can undermine the patient's self-reliance and ability to use their own skills to solve mental health problems.
* High-EE behaviors can be a source of psychological stress, which exacerbates mental illness (the
diathesis–stress model
The diathesis-stress model, also known as the vulnerability–stress model, is a psychological theory that attempts to explain a disorder, or its trajectory, as the result of an interaction between a predispositional vulnerability, the diathesis ...
).
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
Nonverbal communication (NVC) is the transmission of messages or signals through a nonverbal platform such as eye contact, facial expressions, gestures, posture, and body language. It includes the use of social cues, kinesics, distance (proxemi ...
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.
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.
Brown devised the five dimensions of expressed emotion to quantify the interpersonal environmental exposures of patients.
The advantage of a low-EE environment has been cited to partly explain the success of the Belgian village of
Geel
Geel () is a city located in the Belgian province of Antwerp, which acquired city status in the 1980s. It comprises Central-Geel which is constituted of 4 old parishes a/o towns: Sint-Amand, Sint-Dimpna, Holven and Elsum. Further on around the cen ...
, where residents have for hundreds of years welcomed unrelated people with mental illness to live with them.
[The Problem with the Solution (transcript)](_blank)
- Invisibilia
''Invisibilia'' is a radio program and podcast from National Public Radio, which debuted in early 2015 and "explores the intangible forces that shape human behavior—things like ideas, beliefs, assumptions and emotions." The program's title com ...
podcast, 1 July 2016
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
Problem solving is the process of achieving a goal by overcoming obstacles, a frequent part of most activities. Problems in need of solutions range from simple personal tasks (e.g. how to turn on an appliance) to complex issues in business an ...
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.
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.
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.
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.
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.
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.
Validity
Some studies show that there is no link between expressed emotion and first episode psychosis, illness severity,
age of onset
The age of onset is the age at which an individual acquires, develops, or first experiences a condition or symptoms of a disease or disorder. For instance, the general age of onset for the spinal disease scoliosis is "10-15 years old," meaning t ...
, and illness length.
There is also literature that links EE to the course and outcome of numerous major childhood psychiatric disorders. One study
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
Social anxiety disorder (SAD), also known as social phobia, is an anxiety disorder characterized by sentiments of fear and anxiety in social situations, causing considerable distress and impaired ability to function in at least some aspects ...
, it has been found parents' high level of expressed emotion (emotional overinvolvement, criticism, hostility) is strongly associated with treatment outcome in their children.
See also
*
Social defeat
Social defeat is a concept used in the study of the physiological and behavioral effects of hostile interactions among either conspecific animals, or humans, in either a dyadic or in a group-individual context, potentially generating very signific ...
*
Double Bind
A double bind is a dilemma in communication in which an individual (or group) receives two or more reciprocally conflicting messages. In some scenarios (e.g. within families or romantic relationships) this can be emotionally distressing, creating ...
References
Further reading
*
*
External links
* http://www.personalityresearch.org/papers/mcdonagh.html
{{DEFAULTSORT:Expressed Emotion
Emotional issues