Expressed Emotion In Caregivers Research Articles

Psychological well-being in persons with dementia: The role of caregiver expressed emotion.

Dementia is a growing health concern. Persons with dementia experience higher levels of anxiety and depression, which correlates with poorer quality of life, disability and hospitalization. This is one of the few studies to use a longitudinal design to assess the impact of expressed emotion (EE) on well-being in dementia over time. Sixty-one people with dementia and their main informal caregiver were recruited from memory services. Caregiver EE was coded from a Camberwell Family Interview conducted at time one. Person with dementia's outcome measures (quality of life, depression and anxiety) were collected at time one and at 6-months follow-up. Caregiver high EE was associated with higher levels of depression in people with dementia and greater anxiety at follow-up. Emotional over involvement predicted greater anxiety and critical comments predicted greater depression. Low EE appeared to have a protective effect on well-being in people with dementia. People with dementia with low EE caregivers experienced a small reduction in depression and anxiety over time, whereas those with high-EE caregivers maintained baseline levels of depression and anxiety. Caregiver high EE is associated with poorer psychological outcomes for people with dementia over time. Psychological therapies, such as cognitive behavioural therapy informed family interventions should be used to reduce high EE within carer and person with dementia relationships.

Expressed emotion and treatment outcome in higher levels of care for eating disorders.

Expressed emotion (EE) among caregivers toward the affected offspring is a negative prognostic indicator for adolescent patients with eating disorders (EDs) in outpatient treatment. Less research has examined its impact on adolescents in higher levels of care (HLOC). The current study examined differences in caregiver EE according to the subtype of anorexia nervosa (AN) (restricting [AN-R] versus binge/purge [AN-BP]), and level of care (LOC). We also examined the main effects of baseline caregiver EE (emotional overinvolvement [EOI] or criticism), AN subtype, and their interaction on eating pathology and depression at discharge. Adolescent patients (N=203) receiving treatment at HLOCs completed measures of ED pathology (Eating Disorder Examination-Questionnaire) and depression (Patient Health Questionnaire-9) at baseline and discharge, and one caregiver of each patient completed a measure of EE (Family Questionnaire) at baseline. No differences in caregiver EE were found between patients with AN-R versus AN-BP, or relative to LOC. Caregiver EE did not predict outcome for ED symptoms or depression at discharge. The impact of high caregiver EE may be less substantial at HLOCs than outpatient care given that caregivers are less involved in treatment at HLOCs. Future research is needed to determine if high caregiver EOI leads to poor treatment outcome for adolescents as it does for adults, or whether it is an appropriate expression of care for patients who are ill enough to require HLOC treatment. High caregiver EE was not found to predict treatment outcome for adolescents with eating disorders in higher levels of care (HLOCs), possibly due to the limited involvement of caregivers in HLOCs. However, patients step down to outpatient treatment, where high caregiver EE can have a significant negative impact on outcome. HLOCs should incorporate efforts to reduce high caregiver EE in anticipation of step-down to outpatient treatment.

Caregiver Expressed Emotion in Families of Youth With Spina Bifida: Demographic, Medical, and Family Correlates.

Caregiver expressed emotion (EE), an interview-based measure of emotional valence within an interpersonal relationship, is associated with psychosocial outcomes across multiple conditions. Guided by a model implicating a bidirectional role of "Chronic Family Stress" in the unfolding of EE in family environments, the current study examined demographic, medical, and family-level variables in association with EE in caregivers of children with spina bifida (SB). Data were combined from 2 distinct studies of families with a child with SB, resulting in a sample of 174 (ages 8-17). Linear regressions examined the family stressors and child variables in association with maternal and paternal warmth and criticism, as coded from EE interviews. Higher levels of family stress were associated with paternal criticism (p = .03), while having non-Hispanic White children was associated with both maternal and paternal criticism (ps < .005). Having children younger in age (ps < .01) and without a shunt (ps < .01) was associated with higher warmth. Family stressors, absence of the negative impacts of systemic racism, shunt status, and age appear to be associated with the expression of EE in caregivers of a child with SB. Findings highlight multiple assessment considerations, including assessing EE when children are younger to engage caregivers with children with SB when they are more likely to be expressing more warmth. Pinpointing factors associated with caregiver EE in SB will help to better identify families at risk for high levels of criticism and also aid in the development of targeted prevention and intervention programs.

Do attachment-related differences in reflective functioning explain associations between expressed emotion and youth self-harm?

Youth self-harm is associated with poor health outcomes and attempted and completed suicide. Associations exist between self-harm and expressed emotion (EE), attachment insecurity, and reflective functioning (RF), but these associations are poorly understood. This study evaluates a mediation model in which perceived caregiver EE (pEE) exerts an indirect effect on youth self-harm through attachment insecurity and RF uncertainty. 461 participants aged 16–24 years completed an online survey. Statistical analyses revealed significant direct effects of pEE on attachment insecurity, and of RF uncertainty on self-harm; however, some direct effects were specific to pEE from female caregivers, and attachment insecurity in youth relationships with female caregivers. A significant direct effect of pEE on self-harm was found for pEE from male caregivers only. Significant indirect effects of pEE on self-harm through attachment anxiety and RF uncertainty were found only in relation to female caregivers. The findings encourage family-, attachment-, and mentalization-based approaches to preventing and treating youth self-harm, with a recommendation that caregivers are given adequate support, education, and skills-based training following youth disclosures of self-harm.

Caregiver Expressed Emotion, Quality of Life and Medication Adherence among People Living with Schizophrenia in Nigeria

Background: People Living with Schizophrenia (PLWS) are expected to live longer than before the advent of psychotropic drugs. Relationship of Caregiver Expressed Emotion and Medication Adherence to Quality of Life in African PLWS is not known. The aim of the study was to determine the relationship between the levels of caregiver expressed emotion, quality of life and medication adherence among people living with schizophrenia. Method: Data were collected on Socio-demographic and Schizophrenia Clinical Characteristic, Quality of Life, Caregiver Expressed Emotion (EE) and Medication adherence using Socio-demographic and Schizophrenia Clinical Characteristics questionnaire, World Health Organization Quality of Life (WHOQoL) - Brief, Caregiver Level of EE scale and Morisky Medication Adherence Scale (MMAS) respectively. Results: Caregiver EE was significantly associated with the physical and environmental domains of QoL (p = 0.011 and p = 0.001 respectively). Poor medication adherence correlated positively with the negative attitude and low tolerance sub-scales of the level of EE scale (p = 0.019 and p &lt; 0.001). Medication adherence related significantly to the overall, health-related and physical domains of QoL (p &lt; 0.001, p = 0.017 and p = 0.031). Medication adherence was also a positive predictor of overall QoL (p &lt; 0.001). Conclusion: The High EE has been found to be closely related to the patients’ QoL. The role of medication adherence in promoting QoL among PLWS has been re-emphasized by the findings.

6.26 Lost in Translation: Expressed Emotion and Social Functioning in Youth With Autism Spectrum Disorder

Existing studies substantiate a relationship between high familial expressed emotion (EE) and externalizing behaviors in children with autism spectrum disorder (ASD); however, little is known about the relationship between EE and the severity of core symptoms of ASD, specifically social communication and adaptive functioning. This study assesses the hypothesis that EE demonstrates significant relationships with measures of social cognition, perception of the quality of peer relationships, and adaptive functioning. A preliminary analysis includes 16 adolescents with ASD ages 13 to 17 years old, and 12.5% were female. The Social Responsiveness Scale, Second Edition (SRS-2) was administered to measure social interaction and communication deficits. The Child and Adult versions of the Reading the Mind in the Eyes Tests (RMET-C and RMET-A, respectively) were administered as measures of theory of the mind. The Adaptive Behavior Composite score from the Vineland-3 (VABS-3) assessed adaptive functioning. The NIH Patient-Reported Outcomes Measurement Information System (PROMIS) measure was used to evaluate the perception of quality of peer relationships. EE was determined using the Five-Minute Speech Sample. There was a nonsignificant difference in the hypothesized direction between SRS-2 total score (p = 0.34), Social Communication subscale score (p = 0.34), and Social Communication and Interaction DSM-5–compatible subscale score (p = 0.36) between the high and low EE groups. On the RMET-C and -A, subjects with high caregiver EE had similar error rates as those with low EE (p = 0.18 for RMET-C and p = 0.36 for RMET-A). There was no significant difference between the groups on the VABS-3 (p = 0.86). High EE youth rated the quality of their peer relationships lower by 4.9 points on the PROMIS Peer Relationship scale than individuals with low EE (p = 0.16). Although these preliminary results do not support our hypotheses, the nonsignificant differences were in the hypothesized direction. Our sample size was small (N = 16) and likely lacking the power needed to identify significant differences in the social communication of youth with ASD living with low vs high degrees of caregiver EE. Directions for future study include reexamining these hypotheses with a larger sample size and identifying directionality in the association between EE and core deficits.

Interaction of caregiver-expressed emotions and neuropsychiatric symptoms in persons with dementia: a longitudinal cohort study

ObjectivesNeuropsychiatric symptoms (NPS) have a major impact in persons with dementia (PwD). The interaction between the caregiver and the person with dementia may be related to the emergence of NPS....

Affective temperament traits may explain high expressed emotion in caregivers of patients with Alzheimer's disease.

The negative interactions between Alzheimer's disease (AD) patients and their caregivers may provoke criticism, hostility, and emotional overinvolvement that characterise highly expressed emotion (EE) attitudes. In this study, we hypothesised that affective temperament traits of AD caregivers are related to their high EE levels independent from other patient and caregiver characteristics. Eighty AD patients were assessed through Clinical Dementia Rating Scale (CDR), and Mini-Mental State Examination. Expressed Emotion Scale (EES), Temperament Evaluation of Memphis, Pisa, Paris and San Diego auto-questionnaire, and Hamilton Depression Rating Scale were applied to the caregivers. The high (n = 41) and low EE caregivers (n = 39) were compared with respect to some sociodemographic and clinical characteristics of the patients and caregivers, and affective temperament traits of caregivers. The associations of caregiver EES scores with multiple variables related to patients and caregivers were examined by Pearson correlation tests. We performed multiple linear regression analysis to determine the possible predictors of total EES scores. High EE caregivers had significantly higher depressive, cyclothymic, and anxious temperament traits than in low EE subjects. A weak positive correlation was found between the total EES scores and Personal Care scores of CDR. Home and hobbies subscale scores of CDR had a moderately significant positive correlation with total EES scores. There was also moderate significant positive correlations between total EE scores and depressive, cyclothymic, anxious, and irritable temperament traits. Linear regression analysis indicated that depressive temperament significantly predicted the high levels of caregiver EE. These findings suggest that caregivers' depressive temperament is predominantly related to their EE levels even after controlling for the severity of AD, and lower educational level of caregivers. Our results may provide evidence that high EE might be a reflection of caregivers' depressive temperament traits, in accordance with the trait hypothesis.

Risk and Resiliency Factors Related to Dementia Caregiver Mental Health.

Prevalence rates for dementia are expected to rise exponentially as the elderly population rises. With this comes a corresponding increase in the number of family members who will become dementia caregivers. Caregivers of people with dementia often experience a deterioration in mental health. Identifying factors that relate to caregiver mental health is necessary to develop appropriate interventions. The current study explored how family functioning (measured with a latent variable that includes family cohesion, family balance, and family communication), caregiver expressed emotion (EE), and patient symptom severity related to caregiver mental health (measured with a latent variable that includes depression, anxiety, and stress). Participants included 107 dementia caregivers. The following specific hypotheses were tested: lower levels of both (1) EE and (2) patient symptom severity, and (3) higher levels of family functioning would be related to better caregiver mental health. Results produced a well-fitting model: X2 (18)=14.858, p=.672; CFI=1.00; RMSEA=.00; SRMR=.037. Moreover, results indicated that better family functioning (Ɣ=-3.54, SE=1.34, p=.008), lower levels of caregiver EE (β=.36, SE=0.07, p<.01), and higher patient symptom severity (β=-3.03, SE=0.88, p=.001) were related to better caregiver mental health. Results from this study suggest that efforts to bolster family functioning (i.e., enhance communication, promote cohesion, encourage flexibility) could help improve caregiver mental health.

Reduction of High Expressed Emotion and Treatment Outcomes in Anorexia Nervosa-Caregivers' and Adolescents' Perspective.

High expressed emotion (EE) is common in caregivers of patients with anorexia nervosa (AN) and associated with poorer outcome for patients. In this study, we examined the prevalence of high EE in caregivers of adolescents with AN and analyzed predictors for EE using multivariate linear regression models. We further analyzed whether EE is reduced by the “Supporting Carers of Children and Adolescents with Eating Disorders in Austria” (SUCCEAT) intervention using general linear mixed models and whether a reduction of EE predicts patients’ outcomes. Caregivers were randomly allocated to the SUCCEAT workshop (N = 50) or online intervention (N = 50) and compared to a comparison group (N = 49). EE and patients’ outcomes were assessed at the baseline, post-intervention, and at the 12-month follow-up. Up to 47% of caregivers showed high EE. Lower caregiver skills, higher AN symptom impact, higher levels of depression and motivation to change in caregivers were significant predictors for high EE. EE significantly decreased in the SUCCEAT groups and the comparison group according to the caregivers’, but not the patients’ perspective. The level of reduction could partially predict subjective improvement and improvement in clinically assessed AN symptoms and body mass index of patients. Implementing interventions for caregivers addressing EE in the treatment of adolescents with AN is strongly recommended.

Caregiver expressed emotion as mediator of the relationship between neuropsychiatric symptoms of dementia patients and caregiver mental health in Hong Kong

Objectives: Quality of life among Hong Kong’s family dementia caregivers is a current heightened public health concern. This was one of the first East Asian studies to examine the role of family expressed emotion (EE) in the negative caregiver outcomes associated with dementia caregiving. EE comprises overinvolved and critical communications in families of people with mental illness. In this research, caregiver EE was evaluated as a mediator of the relationship between behavioral and psychological problems associated with dementia (BPSD) and negative caregiver outcomes.Method: Participants were 89 Hong Kong family caregivers (79% female, 84% married, 43% >50 years of age) of people with diagnosed dementia, recruited from elder day care centers. Caregivers completed the Neuropsychiatric Inventory (NPI), Cohen Mansfield Agitation Inventory (CMAI), Level of Expressed Emotion scale (LEE), Zarit Burden Interview, and Center for Epidemiological Studies Depression Scale (CES-D).Results: Agitation, delusions, hallucinations, aggression and irritability were BPSD most associated with caregiver burden and depression. EE significantly mediated the BPSD-negative caregiver outcome relationship. Among EE subscales, intrusiveness was significantly more common and less associated with negative caregiver outcomes. Caregiving hours, low family support, and religious nonaffiliation were associated with EE and poorer caregiver outcomes.Conclusions: The negative impact of BPSD on dementia caregivers in Hong Kong is influenced by EE. Higher scores on EE intrusiveness may be partly accounted for by filial piety, a strong sense of family responsibility characterized by high attentiveness to elderly family members. As EE is a potentially modifiable factor, interventions are considered.

Effectiveness of guided self-help in decreasing expressed emotion in family caregivers of people diagnosed with depression in Thailand: a randomised controlled trial.

BackgroundHigh expressed emotion (EE) can extend the duration of illness and precipitate relapse; however, little evidence-based information is available to assist family caregivers of individuals with depression. In the present exploratory study, we examined the effectiveness of a cognitive behaviour therapy (CBT) based guided self-help (GSH) manual in decreasing EE in caregivers of people with depression, in Thailand.MethodA parallel group randomised controlled trial was conducted, following CONSORT guidelines, with 54 caregivers who were allocated equally to GSH or control group (standard outpatient department support). In addition, both groups were contacted weekly by telephone. EE was assessed, using the Family Questionnaire (FQ), at baseline, post-test (Week 8) and follow-up (Week 12).ResultsFQ scores at baseline indicated that both groups had similar, though moderately high level of EE. However, between baseline and post-test EE scores decreased markedly in the intervention group, but in contrast, they increased slightly in the control group. Between post-test and follow-up, little change took place in the EE scores of either group. Overall, the intervention group recipients of GSH showed a significant decrease in EE whereas the control group recipients of standard outpatient department support reported a slight increase in EE.ConclusionThese findings provide preliminary evidence that GSH is beneficial in reducing EE in caregivers, which is advantageous to family members with depression and caregivers. The approach may be used as an adjunct to the limited outpatient department support given to caregivers by mental health professionals and, perhaps, to caregivers who do not attend these departments.Trial registrationAustralian and New Zealand Clinical Trials Registry https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=366639. Registered 21 July 2014.

Determinants of obsessive compulsive disorder

Background: The family has a significant role both in the genesis and prognosis of obsessive-compulsive disorder (OCD). Early identification, treatment and prevention of relapse in patients with OCD have important therapeutic and psychosocial implications. Hence, to study and determine family factors like high expressed emotion (EE) and family dysfunction are essential. These two factors play a significant role in the relapse and course of OCD. Aim: The aim was to study the relationship between family function, EE and OCD. Materials and Methods: The sample included 30 patients who were diagnosed with OCD using International Classification of Diseases-10 Diagnostic Criteria for Research criteria. Yale-Brown obsessive compulsive scale was used to assess the severity of OCD. EE was assessed in cases using Family Emotional Involvement and Criticism Scale and family function was assessed in cases using the family interaction pattern scale (FIPS). Statistical analysis was performed using Statistical Packages for Social Science. Patient and caregivers of the patients were assessed on self-developed socio-demographic proforma. Pearson co-relation co-efficient test was used to study the correlation between OCD, high EE and family dysfunction. Results: The result showed that there are significant correlations between high EE, family dysfunction and OCD. The Pearson correlation co-efficient between OCD and EE shows a significant correlation between the high EE of the caregiver and OCD with P < 0.01. The Pearson correlation co-efficient between OCD and Family Interaction Pattern Scale shows a significant correlation between the family dysfunction of the caregiver and OCD. Conclusion: Impaired family function and high EE in caregivers associated with OCD. Thus clinical interventions may improve the functional abilities of the caregivers.

Perceptions of family criticism and warmth and their link to symptom expression in racially/ethnically diverse adolescents and young adults at clinical high risk for psychosis.

Little is known about the role of expressed emotion (EE) in early symptom expression in individuals at clinical high risk (CHR) for psychosis. In patients with established schizophrenia, the effects of EE on clinical outcomes have purportedly varied across racial/ethnic groups, but this has not yet been investigated among CHR patients. Furthermore, studies have traditionally focused upon caregiver levels of EE via interview-based ratings, whereas the literature on patient perceptions of caregiver EE on psychosis symptoms is relatively limited. Linear regression models were conducted to examine the impact of criticism and perceived warmth in the family environment, from the CHR patient's perspective, on positive and negative symptom expression in non-Latino white (NLW; n = 38) and Latino (n = 11) adolescents and young adults at CHR for developing psychosis. Analyses examining the sample as a whole demonstrated that perceived levels of maternal criticism were negatively associated with negative CHR symptomatology. Additional analyses indicated that race/ethnicity moderated the relationship between criticism/warmth and clinical symptomatology. We found evidence of a contrasting role of patient perceived criticism and warmth depending upon the patient's race/ethnicity. Family processes shown to impact the course of schizophrenia among NLWs may function differently among Latino than NLW patients. These findings have important implications for the development of culturally appropriate interventions and may aid efforts to improve the effectiveness of mental health services for diverse adolescents and young adults at CHR for psychosis. Given the small sample size of this study, analyses should be replicated in a larger study before more definitive conclusions can be made.

Further development of a scale of perceived expressed emotion and its evaluation in a sample of patients with eating disorders

High expressed emotion (EE) as measured by the Camberwell Family Interview (CFI) predicts the course of eating disorders (ED). Despite its important contribution to the field, the CFI has two major limitations; it is time-consuming and it does not consider the patient's perspective. Obtaining the patient's view may help shed light on the dyadic nature of caregiver's EE and the patient's illness course. The objectives of our study of 77 patients with ED were to develop further a brief measure to assess the patients' perceptions of their caregivers' EE, the patient version of the Brief Dyadic Scale of Expressed Emotion (BDSEE), and to evaluate its psychometric properties. Three clearly separate factors were identified: perceived criticism, perceived emotional overinvolvement, and perceived warmth. The BDSEE also demonstrated good levels of reliability and construct validity. The BDSEE subscales are significantly related to other measures of the perceived family emotional climate and to the CFI, the gold standard in the field of EE. The clinical implications of the ED patients' perceptions of their caregivers' EE are discussed. Findings support the utility of the expanded BDSEE for both research and clinical practise in assessing the perspective of patients with ED.

Caregiver expressed emotion and depression in Alzheimer's disease

Expressed Emotion (EE) has been a useful construct for understanding the relationship between family interactions and depression in patients with psychiatric disorders. It has not, however, been well studied in patients with Alzheimer's disease (AD) and their caregivers despite its potential utility in clarifying patient-caregiver interactions and how such interactions may affect patient function, and caregiver burden, mood and quality of care. This study investigated the rate of EE in caregivers of patients with AD and depression. It also investigated the relationship of caregiver EE to patient status and caregiver burden and depression. Fifty-seven AD patient-caregiver dyads were studied in a cross-sectional design. Caregiver measures included the EE Speech Sample, Burden Inventory, and Center for Epidemiological Studies-Depression Scale. Patient measures included the Hamilton Depression Rating Scale, Record of Independent Living, and Revised Memory and Behavior Problem Checklist. Twenty-three (40%) caregivers were high in EE, 34 (60%) were low. This percentage is higher than reported in normal older adults but is consistent with other psychiatric populations. High EE caregivers were significantly more likely to be clinically depressed and have higher levels of burden. They also endorsed fewer positive aspects of caregiving. No relationship was found between caregiver EE status and patient variables. Caregiver EE offers a novel approach to understanding important aspects of caregiver-patient interactions which may impact long term patient functioning and caregivers' ability to provide effective care.