Expressed emotions and perceived stress among patients and caregivers of patients suffering from bipolar affective disorder

INTRODUCTION

Expressed emotions (EE) is a measure of the expressed attitude of the relatives towards their psychological patient in their absence.¹

Moreover, EE is a qualitative measure of the “amount” of emotion displayed, typically in the family setting, usually by a family or caretakers. Theoretically, a high level of EE in the home can worsen the prognosis in patients with mental illness or act as a potential risk factor for the development of psychiatric disease.² In addition, EE exist in both patient as well as their caregivers. As current study is focused on EE and perceived stress among bipolar affective disorder (BPAD) patients and their caregivers. Theoretically, a high level of EE in the home can worsen the prognosis in patients with mental illness or act as a potential risk factor for the development or relapse of psychiatric disease.³ It is well proven that high family levels of EE are consistently associated with higher rates of relapse in patients with schizophrenia.⁴ There have been a few studies suggestive of positive association between EE and relapse of psychiatric illnesses.⁵

Miklowitz et al conducted a cohort study to investigate the association between the course of bipolar disorder and EE, affective style, and lithium therapy among 24 patients.

They found a positive association between the families’ EE and relapse.⁶

As BPAD is common major and chronic mental disorder which enhances the issues related to expressed emotions. EE reflects the attitude like anger, hostility, frustration, stress, criticism of a closed relative towards BPAD family member. Therefore, EE is an important factor in the recovery process of those having psychological illnesses.⁷

Kupier’s research focused on EE that it has progressed rapidly with growing years as there are many studies suggestive of relationship between EE of family members and relapse in schizophrenia, BPAD and eating disorders patient.⁸

Expressed emotion among caregivers

The EE is thought to be an adverse family environment mainly including the quality of interaction pattern and type of family relationships between the family caregivers and patients with the psychiatric disorders.

The ability of the family caregiver to contribute to the management of a chronic disease by providing quality care to their patient is a significant health care resource. Besides these all caregiver remain occupied with lot of responsibilities related to home and patient care therefore he is a sufferer during patient psychiatric illness as he has no source of catharsis and no time for fulfillment of his needs.⁹

EE is a significant characteristic of the family environment which has been found to be a predictor of symptom relapse in several mental disorders.¹⁰ Relative of patients experience a mixture of emotions varying from loss and grief to anger and guilt. They may also experience feelings of rejection, irritability, ignorance, blaming and negligence. They too, feel isolated and stigmatized like their patients. Their lives are disturbed by providing more care than normally appropriate care to someone of the patients’ age. In addition to the already existing family roles, the role of being a caregiver becomes stressful for the individual, both psychologically and economically.¹¹

Perceived stress

Perceived stress is the feelings or thoughts that a person has, related to the amount of stress he or she is under at a given time or over a given period of time.¹²

Perceived stress includes feelings about the inability of a person to control and predict one`s life, the irritating matters one has to handle often, the changes occurring in one`s life, and the confidence of a person in their ability to deal with problems or difficulties one may face.¹³ In psychiatric patient, it does not measure the types or frequencies of stressful events which happen to a person and his care givers, instead it measures an individual’s feelings about the general stress in their life and their ability to tackle such stress of mental illness.¹⁴ Individuals who may have suffered similar negative life events may react differently to the impact or severity of these situations due to factors such as personality, coping strategies and support. In this way, perceived stress marks the interaction of an individual with their environment which includes burden of the patient with mental illness and their expressed emotions.¹⁵

Therefore, main objective of current study was to assess expressed emotions and perceived stress among patients and caregivers of patients suffering from BPAD.

METHODS

Descriptive research approach was used for this study. BPAD patients and their caregivers attending psychiatry unit (ward and OPD) of PGIMER, Chandigarh were enrolled 50 in each group by using purposive sampling technique during the 10 days of March month. Written ethical justifications and ethical permissions were taken from departmental concerned authorities before conduction of study and data collection. Patients and caregivers of patients with BPAD who were able to read Hindi or English were included and patients diagnosed with psychotic disorders were excluded. For data collection three tools were used as socio- demographic profile of patients and their care-givers, modified version of Hooley’s expressed emotions tool, modified version of Sheldon Cohen’s perceived stress scale. Socio-demographic profile includes age, sex, residence, marital status, educational status, occupation, religion, family type, family income and family history of mental illness. The scale for assessing the level of EE consists of 4 domains-emotional support, criticism, irritability, intrusiveness. Every domain further consists of items-emotional support consists of 13 items, criticism consists of 4 items, irritability consists of items, and intrusiveness consists of 5 items. Every item covers 3 responses-disagree, agree and neutral. The scoring for the same was disagree (2), agree (1) and neutral (0). The perceived stress scale was used to check the respondents’ opinion regarding the unpredictability, uncontrollability and overloaded characteristic of life. The scale also included a number of direct questions about the current levels of experienced stress. PSS scores were obtained by reversing responses (i.e. 0=4, 1=3, 2=2, 3=1 and 4=0) to the 4 positively stated items 4, 5, 7 and 8 and then summing up all items on the scale.¹⁶

The data was collected using semi- structured interview method. Each of the subjects was interviewed separately.

RESULTS

Data was analyzed using descriptive statistics in statistical package for the social sciences (SPSS) version 16.0. The analyzed data was presented in the form of tables and figures. Table 1 depicts the significant findings in patients as well as their caregivers according to socio–demographic variables.

Table 2 depicts the results for EE under four domains of emotional support, criticism, irritability and intrusiveness in patients as well as their caregivers.

Table 3 depicting the findings related to perceived stress among patients and their caregivers for 10 items with likert scale scoring as never, almost never, sometimes, fairly often and very often respectively.

DISCUSSION

The current study was conducted with an objective to explore the level of expressed emotion and perceived stress among patients suffering from BPAD and their caregivers by sampling 50 patients and their caregivers. The data was collected through interview method with standardized tools from all age groups over a period of one week. The findings of current study showed that 64% of caregivers face criticism from their patients while 62% of patients face criticism from their caregivers. The study also shows that majority 68% patients provide emotional support to their caregivers. Maximum about 66% patients have moderate perceived stress as compared to their caregivers which is 52%.

In 2016 Indira Gandhi Government Medical College and Hospital, Nagpur conducted an exploratory study to assess the expressed emotions among caregivers of patients with mental illnesses. They collected data among 100 caregivers. The results of study showed that 97 caregivers among 100 had severe emotional involvement score which shows that majority caregivers had high EE.¹⁷

A study on EE in psychiatric disorder conducted by Mohapatra concluded that relapse rate of schizophrenia patients whose caregivers high EE is 48% and 21% in patients with low EE caregivers. Patients with high EE reported higher depression over 2 years follow up regardless of treatment.¹

Despite the differences in languages, culture or country, care giving has become everyday part of life for millions of people around the globe. It is invisible yet valuable care. It is essential that researchers around the world continue to explore the link between care giving and its impact on careers’ emotional and physical health. Cross cultural research on expressed emotions was conducted in diverse countries such as Australia, Germany, Denmark, Italy and India. Despite cultural differences in the definition and interpretation of the terms like criticism, hostility and emotional over involvement, the cross culture EE researches showed a similar trend.²

It can be concluded that high EE and perceived stress have proven to be major stressors for families resulting from relationship problems between caregivers and patients with mental illness and are also a significant predictor of the course of illness for BPAD. Hence, the psychosocial interventions which focus on families strongly emphasize on reduction of the levels of EE among caregivers by increasing their knowledge about their patient’s illness.

CONCLUSION

The current study highlights that caring for a person with BPAD can develop high expressed emotions and negative emotional atmosphere among the caregivers of patients with BPAD, which causes not only relapse in patients but also puts its impact on the course of illness. Hence the family intervention approach should be used in order to manage the patient and family in all aspects. It also helps the caregivers in lowering their expressed emotions, perceived stress and enhance their coping strategies.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the institutional ethics committee

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