Expressed Emotion Types in Psychiatric Illnesses
Definition and Core Components
Expressed emotion (EE) in psychiatric illnesses consists of two primary types: negative expressed emotions (criticism and hostility) and positive expressed emotions (emotional overinvolvement, warmth, and positive remarks). 1, 2
Negative Types of Expressed Emotion
The negative components of expressed emotion include:
Criticism: The amount of critical comments, disapproval, or negative evaluations made by family members toward the patient, which represents the most robust predictor of relapse across psychiatric disorders 3, 4, 2
Hostility: Generalized negative feelings or rejection directed at the patient as a person (rather than specific behaviors), which predicts worse outcomes particularly in schizophrenia and related psychoses 3, 4, 2
Emotional Overinvolvement: While sometimes considered separately, excessive emotional overinvolvement can be maladaptive and is assessed as part of the negative EE spectrum, characterized by overprotective, self-sacrificing, or intrusive behaviors 5, 2
Positive Types of Expressed Emotion
The positive components include:
Warmth: Expressions of affection, concern, and empathy toward the patient, which are protective factors 2
Positive Remarks: Favorable comments and expressions of appreciation about the patient, which contribute to better outcomes 2
Clinical Significance Across Disorders
High levels of negative expressed emotion (particularly criticism and hostility) are major predictors of relapse in schizophrenia (hazard ratio 4.90), bipolar disorder, and depression. 3, 5, 2
Impact on Specific Conditions
Schizophrenia and Related Psychoses: Criticism and hostility are the most important risk factors for psychotic relapse, with high-EE environments increasing relapse risk nearly five-fold compared to low-EE settings 3, 4
Bipolar Disorder: The American Academy of Child and Adolescent Psychiatry emphasizes that family dynamics and expressed emotion have a moderating effect on treatment response and relapse rates, with high-EE families showing worse outcomes 1, 5
Depression: Family criticism significantly predicts relapse in major depression, though cultural factors influence the threshold levels that differentiate relapsers from non-relapsers 2
Assessment Methods
Expressed emotion is formally assessed using the Camberwell Family Interview (CFI), which rates criticism, hostility, emotional overinvolvement, warmth, and positive remarks through structured interviews with key relatives. 2
Alternative assessment tools include:
Family Attitude Scale (FAS): A self-report measure that correlates with CFI findings but may assess somewhat different constructs, with only 14-25% shared variance 5, 6
Perceived Criticism Measure (PCM): Assesses the patient's perception of family criticism, though its predictive value for relapse is questionable and less reliable than objective EE ratings 6, 2
Treatment Implications
Family-focused interventions specifically targeting reduction of negative expressed emotion (criticism and hostility) while enhancing positive components (warmth and positive remarks) significantly decrease relapse rates across psychiatric disorders. 1, 5
The American Academy of Child and Adolescent Psychiatry recommends that family intervention programs should:
Provide structured psychoeducation about the illness to reduce unrealistic expectations that fuel criticism 1
Enhance communication skills and problem-solving abilities to decrease hostile interactions 1
Promote stable, supportive family relationships that buffer against relapse 1, 5
Common Pitfalls
A critical pitfall is treating patients in isolation without addressing family expressed emotion patterns, as high-EE environments can undermine even optimal pharmacological treatment. 1
Additional considerations:
Cultural factors significantly influence EE thresholds and manifestations, requiring culturally appropriate assessment and intervention strategies 5, 2
Patient characteristics including illness duration, number of hospitalizations, and comorbid personality disorder traits predict higher family EE levels, necessitating early intervention 5, 6, 4
Relatives' unrealistic expectations about patient employment and functioning are robust predictors of criticism, requiring specific psychoeducational focus 4