If, like me, you have already experienced depression, you know how influential those around you are are. It can help us feel better, or it can push us down.
However, when you talk to people who have been close to someone living with a mood disorder (mania or depression), what dominates is the feeling of powerlessness, and the pain, the fear of not knowing what to do.
As a patient, especially when you are still inexperienced, you often only have intuitions about how your loved ones can help. It is almost impossible for us to guide them when we are feeling bad.
(Family Psychoeducation: An Adjunctive Intervention for Children with Bipolar Disorder Mary A Fristad, 2003)
The concept of expressed emotion emerged in England from a series of studies that focused on the relapse rate of adults diagnosed with schizophrenia in the 1960s and 1970s. (Brown et al 1958, 1962,1972) Researchers noted that negative comments, hostility, and over-involvement were correlated with more rapid relapses.
The emotion expressed is used to apprehend this phenomenon. It is the level at which patients' loved ones express critical comments that are hostile, intrusive, or overly emotionally involved in relation to their loved one suffering from a psychological disorder.
Even if one might think that the emotion expressed is a characteristic of the loved one, it mainly reflects the relationship between the loved one and the patient.
(Cook, Kenny, & Goldstein, 1991; Hahlweg et al., 1989;
Hooley, 1990; Simoneau, Miklowitz, & Saleem, 1998).
In the 90s, similar studies were done with people suffering from mood disorders. They showed that the emotion expressed plays a similar role in families of adults suffering from mood disorders.
Priebe et al.,1989, O'connel et al., 1991)
At this stage, I asked myself: what about me? my family? What is the status of it?
Measuring the emotion expressed is not a trivial matter.
The reference method for measuring the emotion expressed is the “Camberwell Family Interview”.
It is a semi-structured interview that lasts between one and two hours carried out with the key member (s) of the patient's family (parents, spouse, etc.) without the patient being present.
It focuses on the patient's behaviors and symptoms in the months preceding a relapse, as well as tensions within the family, daily life, and participation in household chores.
It defines 5 scales measuring:
The use of this questionnaire is limited in practice, as it requires a lot of time to be carried out (2 hours plus 3 hours of analysis), as well as significant training.
For this reason, researchers have developed more rapid assessment methods.
FMSS involves asking the family member to talk about their thoughts and feelings about the patient for 5 uninterrupted minutes.
The speech is recorded to be evaluated later.
It measures critical attitude, emotional over-involvement, and the overall level of emotional expression.
But unlike the Camberwell Family Interview, it doesn't measure hostility or heat. It does, however, count the number of positive comments, which is used to measure emotional overinvestment.
The questionnaire only takes 20 minutes of analysis in order to obtain the emotional expression score. It therefore makes it possible to democratize the concept of expression expressed.
However, it has the defect of being less sensitive in detecting people with a high level of expression expressed than the Camberwell Family Interview. It is therefore less reliable.
The FAS (Kavanagh et al., 1997) is a questionnaire of the emotion expressed. Relatives or patients can complete it.
The questionnaire contains 30 statements, for example: “I wish he wasn't there.”
For each, the person should say how often this statement is true right now on a scale ranging from “Every day” to “Never.”
Sorry for the English (feel free to use an online translator;)
“The family attitude scale: reliability and validity of a new
Scale for measuring the emotional climate of families, Kanvanagh 1997”
Table 1
The Family Attitude Scale
1. It is good to have him around (a)
2. He Makes Me Feel Drained
3. He ignores my advice
4. He is really hard to take
5. I Shout at Him
6. I Wish He Were Not Here
7. I feel that he is Driving Me Crazy 8. I Lose My Temper With Him
9. He is easy to get along with (a)
10. I Am Sick of Having to Look After Him
11. He causes me problems
12. I Enjoy Being With Him (A, B)
13. He is a real burden
14. I Argue With Him
15. I Feel Very Close to Him (a)
16. I Can Cope With Him (a)
17. Living With Him Is Too Much For Me
18. He is infuriating
19. I Find Myself Saying Nasty or Sarcastic Things to Him
20. He appreciates what I do for him (a)
21. I feel that he is becoming easier to live with (a)
22. I Wish He Would Leave Me Alone
23. He Takes Me for Granted
24. He Can Control Himself (a)
25. He is hard to get close to
26. I Feel That He Is Becoming Harder to Live With
27. I Feel Very Frustrated With Him
28. He makes a lot of sense (a)
29. I Feel Disappointed With Him
30. He Tries to Get Along with Me (a)
Note. Items are rated 4 every day., 3 most days., 2 some days., 1 very rarely., 0 never..
(a) Reverse scores.
(b) Item 12 was derived from the Patient Rejection Scale Kreisman et al., 1979..
It is the simplest measure of the emotion expressed. Since the most important element of the emotion expressed in predicting relapses is how the patient views their loved ones as being critical, perceived criticism is measured by simply asking the patient to rate on a scale of 1 to 10 how critical their loved one is of them.
In addition, they asked the patient to rate on the same scale how critical they were towards their loved one.
The same questions can also be asked to a loved one.
However, it seems that we are unable to measure how critical we are, or not, of someone close to us, and that it is necessary to have it evaluated by an external perspective.
In a 1989 Teadsdale study, researchers noted that how spouses rated how critical they were was uncorrelated with the number of criticisms they expressed when talking about the patient during the Camberwell Family Interview (baseline assessment).
Perceived criticism makes it possible to predict relapses fairly well for schizophrenia and depression.
For bipolar disorder, however, the research findings are a bit different.
In a 2005 study of 360 bipolar patients, relapses were more related to the patients' level of sensitivity to criticism. Those who were most affected by the critics had the most severe symptoms of mania and depression after a year, and they were fine for a smaller number of days during the same period.
For bipolar illness, however, the research findings look
A little different. In a study of 360 bipolar patients,
Miklowitz, Wisniewski, Miyahara, Otto, and Sachs
(2005) Reported that patients' symptomatic outcomes
Were not predicted by the amount of criticism patients
Reported receiving from their relatives. Instead, patients
Who Reported Feeling Most Upset When They Were Criticized
by family members had more severe depressive and
Manic symptoms at 1-year follow-up. They also had a
Lower percentage of days well during the follow-up pe-
The Expressed Emotion Adjective Checklist (EEAC), a self-report measure of EE, has demonstrated validity with adults.
associated with the criticism component of the Five Minute Speech Sample (FMSS), a commonly used EE measure in children.
EEAC scores were also stable and predicted manic symptom severity and global impairment one year later. These data suggest the EEAC may be a useful self-report measure of EE in children.
Measuring Expressed Emotion: An Evaluation of the Shortcuts; Hooley
Level of understanding of the disorder:
Understanding Mood Disorders Questionnaire (UMDQ) (Gavazzi et al 1997)
The first thing for loved ones to lessen their hostility or over-involvement is to help them understand the disease precisely.
Expressed emotion
Emerged as a term from a series of studies that focused on
Relapse rates in adults diagnosed with schizophrenia
(Brown et al 1958, 1962, 1972). Critical comments,
hostility, and emotional overinvolvement (i.e., high EE)
Predicted relapse. While EE was studied initially in
Families of patients with schizophrenia, more recent stud-
Ies have demonstrated that EE plays a similar role in
families of adults with mood disorders (Hooley 1998; Hooley et al 1986; Koenig et al 1997; Miklowitz et al 1988; Simoneau et al 1998). In the Butzlaff and Hooley (1998) recent meta-analysis of 27 studies, they concluded that 1) EE is a general predictor of poor outcome across diagnostic categories and 2) EE can be modified
Assisting families to shift from “emotion focused coping” to “problem focused coping” is a useful strategy (Sloper 1999)
It has been proven that psychoeducation reduces the level of emotion expressed within families. Expressed Emotion reflects the way in which the relatives of bipolar patients express critical, hostile, or over-involved behaviors with respect to their bipolar loved one.
Under the generic term patient education, three types of activities can be identified (WHO): − Patient health education concerns the disease, health and lifestyle behaviors, in a logic of “health culture”. − Patient education about his illness concerns health and disease behaviors relating to treatment, the prevention of complications and relapses and other behaviors related to the existence of a disease, in particular its impact on non-medical aspects of life. − Therapeutic education for The patient involves the part of education directly related to treatment (curative or preventive), a role that is traditionally and exclusively assigned to the caregiver.
http://medias.dunod.com/document/9782100594122/Feuilletage.pdf
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3876031/
https://www.ncbi.nlm.nih.gov/pubmed/27128358
https://ps.psychiatryonline.org/doi/full/10.1176/ps.49.4.531
https://pure.uva.nl/ws/files/3852034/3108_29277y.pdf
Expressed Emotion Concept:
To understand the development of psychoeducation as an
Intervention strategy, a brief review of the concept of
Expressed emotion (EE) is in order. Expressed emotion
Emerged as a term from a series of studies that focused on
Relapse rates in adults diagnosed with schizophrenia
(Brown et al 1958, 1962, 1972). Critical comments,
hostility, and emotional overinvolvement (i.e., high EE)
Predicted relapse. While EE was studied initially in
Families of patients with schizophrenia, more recent stud-
Ies have demonstrated that EE plays a similar role in
families of adults with mood disorders (Hooley 1998; Hooley et al 1986; Koenig et al 1997; Miklowitz et al 1988; Simoneau et al 1998). In the Butzlaff and Hooley (1998) recent meta-analysis of 27 studies, they concluded that 1) EE is a general predictor of poor outcome across diagnostic categories and 2) EE can be modified
Assisting families to shift from “emotion focused coping” to “problem focused coping” is a useful strategy (Sloper 1999)
Proof of Effectiveness
Group psychoeducation
Francesco Colom, 2003 “Group psychoeducation significantly reduced the number of relapsed patients and the number of recurrences per patient, and increased the time of depressive manic, hypomanic, and mixed recurrences. The number and length of hospitalizations per patient were also lower in patients who received psychoeducation.
Conclusion: Group psychoeducation is an effective intervention to prevent recurrence in pharmacologically treated patients with bipolar I and II disorders.
Family psychoeducation versus lighter crisis management training (David J Miklowitz) FFT family-focused therapy
FFT: training for patients and their families 21 sessions over 9 months
Description: information on the disorder, communication and problem solving techniques
Methods: In a randomized controlled trial, bipolar patients were assigned to FFT and pharmacotherapy or a less intensive crisis management (CM) intervention and pharmacotherapy
Change in the real behaviors of families following the training? Theresa L. Simoneau, 1999
Caregiver Concordance concept
Increased disagreement between parents/caregivers on child-rearing matters has been linked to higher rates of child problem behaviors (Jouriles et al 1991), poorer marital quality (Lamb et al 1989), lower levels of family problem-solving (Vuchinich et al 1993), and diminished parental effectiveness (Deal et al 1989).
As individuals with bipolar disorder have a heightened sensitivity to conflict (Miklowitz and Goldstein 1997, p. 42), one might speculate that parental tension caused by disagreements over the most appropriate treatment and methods to manage symptoms of bipolar disorder, a condition that is very trying for families (Hellander et al 2003), would have a deleterious impact on a child's recovery from a manic or depressive episode. Additionally, Cole and Rehm (1986) found that fathers provided significantly less positive reinforcement for their children than did mothers during a challenging task, regardless of whether the child was depressed or nondepressed. This reinforces the findings that mothers and fathers approach parenting tasks differently and that fathers, in particular, may benefit from interventions designed to increase positive parent-child interactions
multifamily psychoeducation groups (MFPG),
Assessment of relatives before studies:
Parents completed the Expressed Emotion Adjective Checklist (EEAC) (Friedmann and Goldstein 1993) and the Understanding Mood Disorders Questionnaire (UMDQ) (Gavazzi et al 1997) before and after workshop attendance.
(Bipolar Disorder and Familly Communication Effect)
The Camberwell Family-EE Interview (CFI; Vaughn & Leff,1976) was administered to significant relatives (parents, spouses, or siblings) while patients were still hospitalized for their index episode or while they were being pharmacologically stabilized on an outpatient basis (on average, 10.7 days, SD = 13.2 days, after the SCID—P interview). The CFI is a
Semistructured interview that focuses on the relative's reactions to the patient's behavior and
symptoms, particularly during the three months prior to the acute episode.
For children:
EEAC scores were also stable and predicted manic symptom severity and global impairment one year later. These data suggest the EEAC may be a useful self-report measure of EE in children.
Psychoeducation groups do not all offer the same formats in terms of number of sessions, frequency (weekly, bimonthly), theoretical reference (tcc, Ipsrt, mixed tcc and Ipsrt program).
Learn more about bipolar disorder
