Expressed emotion


Expressed emotion, is a measure of the family environment that is based on how the relatives of a psychiatric patient spontaneously talk about the patient. It is a psychological term specifically applied to psychiatric patients, and differs greatly from the daily use of the phrase "emotion expression" or another psychological concept "family expressiveness"; frequent communication and natural expression of emotion among family members is a conducive, healthy habit.
Theoretically, a high level of EE in the home can worsen the prognosis in patients with mental illness, such as schizophrenia and social anxiety disorder, or act as a potential risk factor for the development of psychiatric disease. 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. 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 his family feels about him and the disorder. If the patient feels that the parents are too protective, or not caring, the patient may feel that his parents don't care about his independence or trust his judgement. This attitude may cause the patient to relapse, and patients that rate their parents poorly in this test have a harder time coping with their illness if too much time is spent with the parent.
An alternative measures of expressed emotion is the Five Minutes Speech Sample, 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.

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.

Critical comments

Critical attitudes are combinations of hostile and emotional over-involvement. It shows an openness that the disorder is not entirely in the patients control but there is still negative criticism. Critical parents influence the patient’s siblings to be the same way.
The attitudes of family members with high expressed emotion are too strong for the patient and the patient now has to deal with the mental illness and the criticism from those they would need support from in their time of recovery. This stress may cause the patient to relapse and make them fall into a cycle of rehabilitation and relapse. Then the disorder is unsustainable and rehabilitation is required. The only way to escape this cycle is for the family to go through therapy together. This will greatly lower family conflicts and the stress level of the entire household.

Low expressed emotion

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, 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, can be used as an index of problematic parent–child interactions, though the quantifiable effects of emotional overinvolvement, though doubtlessly existent and having huge effects, are not as salient in that study and need to be observed by further studies.
In social anxiety disorder, it has been found parental's high level of expressed emotion is strongly associated with treatment outcome in their children, so parental involvement is warranted
The article "Expressed Emotion and Relapse of Psychopathology" details expressed emotion as a construct, the link between expressed emotion and relapse, evidence of causality, attributions and EE, and more information regarding the theory of EE.