Expressed Emotion among Caregivers of Person with Schizophrenia and Obsessive Compulsive Disorder: A Comparative Study

Background: This is a cross-sectional comparative study with the aim to compare two patient groups of schizophrenia and obsessive compulsive disorder (OCD) and their respective caregivers with the objectives to quantify and compare the expressed emotion (EE) in caregivers of person with schizophrenia and OCD and to study the relationship between them. It also aimed to identify factors associated with expressed emotions in above two groups. Methods: In this study, 40 patients schizophrenia, 40 patients of OCD, along with their 80 respective caregivers were taken on the basis of inclusion and exclusion criteria. Subjects were assessed using Sociodemographic and clinical sheet &FEICS. Appropriate statistics such as mean, standard deviation, unpaired t test, Pearson’s correlation were applied to analyse the data. Result: The results of the study the caregivers of patients with OCD were perceived as having greater over-involvement than the caregivers of schizophrenia. Perceived criticism had a positive correlation with stress whereas over-involvement had a negative correlation. Some of the demographic variables like age and education were also found to have significant correlation with expressed emotion. Conclusion: The presence of significant amount of expressed emotion point out to the need for psychosocial support to the family members for reduction in the expressed emotion.

Several decades of research have established EE as a highly reliable psychosocial predictor of psychiatric relapse. When patients live in a family environment that is characterized by critical, hostile, or emotionally over involved or intrusive attitudes (i.e., in high-EE families), they are at significantly elevated risk of early relapse compared with patients who do not live in such a family environment. The association between high levels of EE and symptom relapse has been well demonstrated for disorders such as schizophrenia and depression. The predictive validity of EE has also been found for a broad range of other psychopathological conditions, including anxiety disorders and substance abuse.

The Components of Expressed Emotion
George Brown explained five components of EE which includes 1. Critical comments 2. Hostility 3. Emotional over involvement (EOI) 4. Positive remarks 5. Warmth Critical comments, hostility and EOI denote high expressed emotion while positive remarks and warmth indicate low EE. High EE relatives less tolerant, less flexible, and more conscientious and report feeling more burdened in the caretaking role. The quantification of critical comments and hostility is greatly reliant on the way in which the respondent uses their tone of voice to convey their feelings (anger, rejection, irritability, ignorance, blaming, negligence, etc.) while the judgment of over involvement also takes into account on the basis of reported behaviour such as caregivers blaming themselves, sacrificing things, being overprotective of patients, excessively being concerned for patients, neglecting personal needs of self, and similar others. Critical attitudes are combinations of hostile and emotional over-involvement. It shows openness that the disorder is not entirely in the patients control but there is still negative criticism. These are basically counted during the interview. Careful observations of direct communications among patients and caregivers prove that Critical caregivers get involved in angry exchanges with the patient whom they seem unable to prevent or to step away from. These potentially lead to physical Violence and it is the nature of some families with high EE. Patients who are unable to get up in the morning, who fail to wash regularly, or who do not participate in household tasks are criticized for being lazy and selfish; unfortunately, in this context, the caregivers fail to understand that these could be potential manifestations of negative symptoms of schizophrenia or any other psychotic disorder. This is reflected in the fact that 70% of critical comments were found to focus on these negative symptoms of schizophrenia rather than on the florid symptoms of delusions and hallucinations. Family caregiver may express in an increased tone, tempo, and volume that patient frustrates them, deliberately causes problems for them. By contrast, low EE caregivers are more capable to recognize aspects of the patient's behaviour which are a manifestation of the illness.
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. Hostility is expressed by general criticisms or attitudes that are rejecting of the patient.
EMOTIONAL OVERINVOLVEMENT It is termed emotional over-involvement when the family members blame themselves for the mental illness. EOI manifests itself by over-emotionality, excessive self-sacrifice, overidentification, and extreme overprotective behaviour with the patient. These family members feel that any negative occurrence is their fault and not the disorders and suffer from chronic guilt. 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. Unfortunately, this discourages the person's skills and self-reliance, so that in the long run, over protectiveness hampers the person's recovery. It also leads to dependence of the patient on their caregiver. The pity from the relative causes too much stress and the patient relapses to cope with the pity.
EOI is most commonly shown by parents, especially mothers, and occasionally by fathers, but rarely by other relatives.

WARMTH
It is assessed based on kindness, concern, and empathy expressed by the caregiver while talking about the patient. It depends greatly on vocal qualities with smiling being a common accompaniment, which often conveys an empathic attitude by the relative. Warmth is a significant characteristic of the low EE family.

POSITIVE REGARD
Positive regard comprises of statements that express appreciation or support for Patient's behaviour and verbal/nonverbal reinforcement by the caregiver.

Measuring Expressed Emotion
There is a scale that is used in the Camber well Family Interview of the family to categorize. The three major expressed emotion scales are critical, hostility, and emotional over-involvement that are used to determine whether the expressed emotion is high or low (Hooley & Hoffman 1999). All of the scales are taken into consideration while watching the tape of the relatives that were interviewed. The answers and reactions of the family members are carefully observed. Those in the interview with high expressed emotion were considered very critical and not very tolerant of the feelings of the patient (Hooley, 1986). This attitude comes across too strong for someone who is trying to make progress in an illness. The person with the illness now has to deal with their own sickness and the criticism from those needed for support through these tough times.

High Expressed Emotion
Once the taped is watched and carefully analysed, the type of expressed emotion is decided. Those who are decided to have high expressed emotion are very critical and hostile. They do not know any other way to help support the family member because they feel like they are helping. They feel that the illness is internal and can be controlled by this person. The only way they feel that the person will change their behaviour is through criticism which actually causes the relapse. (Wendel, Miklowitz, Richards, & George, 2000). Those with high expressed emotion also criticize behaviours' that do not relate to the psychological disorder but more to the unique person. A person's attitude toward a person, especially when they are very critical, takes a long time to change their way of thinking. High expressed emotion is more likely to cause a relapse than low expressed emotion because of the aggressive verbal criticisms they made (Weisman, Nuechlerlein, Goldstein, & Snyder, 1998).

Low Expressed Emotion
Low expressed emotion differs from high expressed emotion in that the relatives are more conservative with their criticism. Relatives feel that the family member does not have control over the disorder and sympathize with them. This is because there is also more information about disorders in which some relatives have more knowledge of the illness than others, which makes them more understanding and less critical. Families also vary because some do not have to put up with difficult family members that have a mental disorder. These are some reasons for expressed emotion to be low instead of high. The family is more educated and accepting of the disorder than those of high expressed emotion (Weisman et al., 1998). The disorder is accepted to be external, not internal and out of the control of the patient. The relatives may have some criticism about the disorder and the behaviour, but they do not always express it towards them (Wendel et al., 2000). Low expressed emotion is a different stress from high expressed emotion because it is less stress toward the patient.
There is another way to measure the amount of expressed emotion that is in a household, and it is taken from the point of view of the patient. The perception of everyone around them shows how they feel about what is thought of them and the disorder they have. A study was conducted with patients who have schizophrenia that will live in the same house as their parents. The patients would rate their parents according to a scale of care and protection. Those who rated their parents with high protection or low care were found to have a harder time with the illness if there too much contact with their parents (Cutting & Docherty, 2000). The parents come across too strong or not strong enough for those who are dealing with schizophrenia. This causes the child Parents can cause their child to relapse because of their behaviour toward the child. Those who blame themselves for their child's illness are higher in emotional over-involvement, commonly found in females (Peterson & Docherty, 2004). They become too involved with their child because they feel like it is their fault that the illness exists. This type of emotion is overwhelming for someone who is trying to improve their life. The parent shows a lot of concern toward the child, but it does not necessarily mean that this is productive for them. The over involvement causes the child to feel trapped because they feel like they cannot do anything independently. This adds onto the entrapment they have with the psychological disorder that they are trying to handle. The overbearing parents make the child feel helpless because they do not have control; therefore, they fall back into bad habits of their illnesses. Illnesses such as bulimia, anorexia, alcoholism, schizophrenia, and others are triggered by these types of behaviours' from parents and other relatives. The child may feel like the outsider of their family because of the excessive attention they receive as a result of their disorder. The behaviour of everyone around them influences their decision to relapse or progress. (Linda A. McDonagh)

CAREGIVERS PERSONALITY FACTORS AND EXPRESSED EMOTION
Although precise reason for high or low EE attitudes in caregivers is not yet completely unravelled, it has been suggested that EE might partially reflect caregiver's personality traits. Hooley and Hiller found that caregivers of schizophrenia patients, with high EE reported reduced satisfaction of their individual activities, reduced optimism about their future, and reduced selfefficacy compared with low EE caregivers. Moreover, caregivers of high EE were less empathic, rigid, and impatient than low EE caregivers. A critical comment of caregiver is dependent less on the degree of the patient's symptoms than on the caregiver's own personality factors. If a caregiver is easily adjusted to the difficult circumstances and has patience generally, he or she is likely to be a non-critical caregiver. If a caregiver is usually tense or irritable during stressful situations, this stress can result in feelings of anger. All these factors reveal that personality characteristics are significantly related to caregiver's high or low EE.

OPERATIONAL DEFINITIONS: 1. Primary Care givers:
A person who involved in direct care of a mentally ill patient and spent most of their time for caring the patient. This is usually the family member. Depending on culture there may be other members of the family engaged in care. Such as (Father, Mother or Husband, wife or Brother, Sister)-who are providing care for the mentally ill patients. The study sample consisted of caregivers of 40 people with schizophrenic and 40 people with OCD. Table 1 shows the comparison of socio-demographic variables among caregiver groups. There were no significant differences with respect to Gender (X 2 =0.053), marital status (X 2 =0.459), Education (X 2 =0.203) as well as Occupational status (X 2 =0.464) among the two groups. Most caregivers had studied below high school .48.9% of caregivers of Person with OCD were employed compared to 41.5% of caregivers of person with schizophrenia.    Table 3 shows Pearson correlation between socio-demographic profile of patients and expressed emotion respectively. Correlation (r) values are shown in the table. Those who were single had perceived higher criticism (r=0.289). No other significant correlation was observed.

DISCUSSION
This study was conducted on person with schizophrenia and OCD disorder and their caregivers.

DISCUSSION OF METHODOLOGY
The sample size in the present study was 80 in the patient group and 80 in the caregiver group. Thus 40 patients of schizophrenia, 40 patients of OCD and there 80 respective caregivers were included in the study. To examine the sufficiency of the sample, previous related studies were reviewed. The studies on expressed emotion were less. Family emotional involvement and criticism scale (FEICS) by Shields et al were used in the present study to assess expressed emotion respectively. FEICS is also a reliable instrument which has been used in Indian studies for assessment of expressed emotion. Socio-demographic variables such as sex, marital status, residence were compared using chi square. There were no significant differences in the socio demographic profile of patients or caregivers in both groups. Hence, the groups were comparable. The mean age of onset was significantly higher in schizophrenia than OCD.