What are the types of expressed emotions?

Expressed Emotion Types

Expressed emotion (EE) comprises three distinct types: criticism, hostility, and emotional over-involvement, which collectively characterize the quality of affective attitudes and behaviors of family members toward individuals with psychiatric illness. 1, 2, 3

The Three Core Types of Expressed Emotion

Criticism

• Criticism represents negative comments, disapproving remarks, or fault-finding statements directed at the patient by family members or caregivers 1, 3
• This component reflects dissatisfaction with the patient's behaviors, symptoms, or functioning 2

Hostility

• Hostility encompasses generalized negative feelings, rejection, or antagonistic attitudes toward the patient as a person (rather than specific behaviors) 1, 3
• This represents a more pervasive negative emotional stance that extends beyond situational criticism 2

Emotional Over-Involvement

• Emotional over-involvement includes excessive emotional responses, overprotective behaviors, self-sacrificing attitudes, and exaggerated emotional reactions to the patient's condition 1, 2, 3
• This type manifests as intrusive concern, dramatic emotional displays about the patient's illness, or extreme self-sacrifice by caregivers 2

Clinical Significance of EE Classification

High EE environments (characterized by elevated levels of any of these three components) predict increased relapse rates, more frequent hospitalizations, and worse clinical outcomes across psychiatric disorders including schizophrenia and bipolar disorder. 4, 2, 5

• In bipolar disorder specifically, higher EE scores correlate significantly with increased illness duration (r = 0.601, p < 0.001), number of hospitalizations (r = 0.433, p < 0.001), and time spent hospitalized (r = 0.306, p = 0.002) 4
• High EE has proven to be one of the most robust predictors of relapse in schizophrenia across multiple studies 2, 5

Assessment Framework

The Camberwell Family Interview (CFI) remains the gold standard instrument for assessing all three EE components, though alternative measures like the Five Minute Speech Sample or Level of Expressed Emotion Scale serve as acceptable screening tools. 1, 3

• The Family Attitude Scale (FAS) provides quantitative assessment of overall EE levels, with higher scores indicating greater expressed emotion 4
• EE assessment captures the quality of interaction patterns and nature of family relationships between caregivers and patients 2

Critical Clinical Considerations

EE levels are modulated by caregiver age, duration of cohabitation, patient illness severity, and caregiver attribution patterns regarding patient symptoms. 4, 2

• Caregiver age shows significant positive correlation with EE levels (r = 0.404, p < 0.001) 4
• Years of cohabitation correlate with higher EE scores (r = 0.239, p = 0.008) 4
• Family psychoeducation interventions specifically targeting reduction of criticism, hostility, and emotional over-involvement can decrease relapse rates 2, 5