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Expressed emotion (EE), a qualitative measure of the 'amount' of emotion displayed, typically in the family setting, usually by a family or care takers. Theoretically, a high level of EE in the home can worsen the prognosis in patients with mental illness,(Brown et al., 1962, 1972) or act as a potential risk factor (J.R. Asarnow, M. Tompson, S. Woo, D.P. Cantwell. (2004). Is Expressed Emotion a Specific Risk Factor for Depression or a Non Specific Correlate of Psychopathology. Journal of Abnormal Psychology) for the development of psychiatric disease. 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. Answers to questions and non-verbal cues are used to determine if some one 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 (R.L. Butlaff, AM; J.M. Hooley, DPhil.(1998).Expressed Emotion and Psychiatric Relapse.Archives of General Psychiatry).

The three attitudes of emotion shown are hostile, emotional over-involvement and critical. These attitudes are stressful on the recovering patient and influence the outcome of the disorder. Expressed emotion may cause relapse because the patient does not know what to do with the pity and criticism from others.

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.

It is termed emotional over-involvement when the family members blame themselves for the mental illness. This is commonly found in females. These family members feel that any negative occurrence is their fault and not the disorders. The family member shows a lot of concern for the patient and the disorder. This is the opposite of a hostile attitude and a show that the family member is open minded about the illness, but still has the same negative effect on the patient. The pity from the relative causes too much stress and the patient relapses to cope with the pity.

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.

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.

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 patient and his disorder they are more likely to have low expressed emotion. Low expressed emotion causes a different stress and it is directed at the patient less.

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 that they need support from in their time of recovery.

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 effects 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.

The stress from high expressed emotion may cause the patient to relapse. The patient falls into a cycle of rehabilitation and relapse because the stress builds up to much so the only escape is relapse and 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 household.


Some studies show that there is no link between expressed emotion and first episode psychosis and illness severity, age of onset, and illness length (D. Raune, E. Kuipers, P.E. Bebbington.(2004).Expressed emotion at first-episode psychosis: investigating a carer appraisal model.British Journal of psychiatry,184, 322-323)

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