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 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[2][3] or act as a potential risk factor for the development of psychiatric disease.[4] Typically it is determined whether a person or family has high expressed emotion or low expressed emotion 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. It 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 feels that his parents don't care of 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.[5][not in citation given]

An alternative measures 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.[6]

High Expressed Emotion[edit]

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[edit]

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[edit]

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.[7]

Critical Comments[edit]

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[edit]

Low expressed emotion is when the family members are more reserved with their criticism. The family members feel that the patient doesn't have control over the disorder. When the family is more educated and doesn't have to 'put up' with the patient and his/her disorder they are more likely to have low expressed emotion. Low expressed emotion causes a different kind of stress and it is less directly aimed at the patient.

High or low expressed emotion 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. In bipolar patients relapse from manic to depressed can be triggered by a family member's comments. Expressed emotion affects everyone in the home, raising the stress level for everyone. This is bad for the patient's recovery and for the family as a whole. The behavior of everyone around the patient influences the patient to relapse or progress with their illness. Criticism of the patient is hard to stop once it has started.

Validity[edit]

Some studies show that there is no link between expressed emotion and first episode psychosis, illness severity, age of onset, and illness length.[8]

There is also literature that links EE to the course and outcome of numerous major childhood psychiatric disorders. One study[9] showed that one component, high parental dimensions of criticism (CRIT), can be used as an index of problematic parent–child interactions, though the quantifiable effects of emotional overinvolvement (EOI), though doubtlessly existent and having huge effects, are not as salient in that study and need to be observed by further studies.

The article "Expressed Emotion and Relapse of Psychopathology"[10] details expressed emotion (EE) as a construct, the link between expressed emotion and relapse, evidence of causality, attributions and EE, and more information regarding the theory of EE.

See also[edit]

References[edit]

  1. ^ 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. ^ Brown, G., Birley, J., & Wing, J. (1972). Influence of family life on the course of schizophrenic disorder: a replication. British Journal of Psychiatry, 121, 241-258. doi: 10.1192/bjp.121.3.241
  3. ^ Garcia-Lopez, L.J., Muela, J.A. Espinosa-Fernández, L., & Diaz-Castela, M.M. (2009). Exploring the relevance of expressed emotion to the treatment of social anxiety disorder in adolescence. Journal of Adolescence, 32, 1371-1376. doi: 10.1016/j.adolescence.2009.08.001
  4. ^ 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. PMID 11761289. 
  5. ^ 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. 
  6. ^ 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. 
  7. ^ Expressed Emotion IN PSYCHIATRIC DISORDERS: A REVIEW
  8. ^ Raune D, Kuipers E, Bebbington PE (April 2004). "Expressed emotion at first-episode psychosis: investigating a carer appraisal model". Br J Psychiatry 184: 321–6. doi:10.1192/bjp.184.4.321. PMID 15056576. 
  9. ^ 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. 
  10. ^ 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. 

Further reading[edit]

  • Vaughn, Christine; Leff, Julian P. (1985). Expressed emotion in families: its significance for mental illness. New York: Guilford Press. ISBN 0-89862-058-9. 

External links[edit]