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Expressed Emotion among Families of Individuals with Alcohol

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Original Article

Expressed Emotion among Families of Individuals with Alcohol

Dependence Syndrome: A Pilot Study
Kannappa V. Shetty, Sanjeev Kumar Manikappa1, Shreyaa Murthy2, Jagadish Anjanappa3, Vikram Singh Rawat4
School of Social Work, Indira Gandhi National Open University (IGNOU), New Delhi, 1Department of PSS, NIMHANS, 2Department of Psychology, Christ University,
3
Department of Psychiatry, Abhaya Hospital, Bengaluru, Karnataka, 4Department of Psychiatry, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Abstract
Background: Alcohol dependence syndrome (ADS) is a progressive condition stemming from severe alcohol use, where the person becomes
increasingly reliant on alcohol, loses control over its use and will have to increase the quantity of consumption to get the same effect, making it
extremely difficult to stop. This affects various aspects of a person’s life such as the physical health, financial, interpersonal, social, and ethical
life. It also induces negative behaviors such as aggressiveness, risk‑taking attitudes such as drunken driving, legal issues, and withdrawal
from the responsibilities at work and household. Even if the person decides to stop, various stressors might make them fall back into the
same habit. Criticality, hostility, and emotional overinvolvement of the family members toward the patients of ADS, commonly referred to
as expressed emotion (EE), are some of the major causes for relapse Materials and Methods: The sample comprised 31 subjects, who were
selected convenience sampling. The data were collected at a private tertiary care neuropsychiatry hospital, Bengaluru. Ethics approval and
informed consent were taken. Family Emotional Involvement and Criticism Scale and sociodemographic schedule were used. Results: The
perceived criticism was found to be higher (24.6 ± 1.94) than emotional overinvolvement (18 ± 4.48) among ADS caregivers, and the total
score of the EE revealed that there was higher score (42.06 ± 5.2) than the average score of the scale. Conclusion: The study highlights the
need for addressing EE in the families of patients with ADS and to plan for comprehensive psychosocial interventions.

Keywords: Alcohol used disorder, expressed emotion, psychosocial interventions, relapse

Introduction in recurrent arguments with spouse, children, parents, and

other family members. This can eventually lead to violence,
In India, alcohol consumption has increased drastically from
withdrawal from household and work, risk‑taking attitudes
past two decades, and more than half of individuals are in
such as drunken driving, getting arrested for alcohol related
the category of hazardous drinking.[1,2] Alcohol dependence
disorderly conduct, and causing recurrent legal issues.[10‑12]
syndrome (ADS) is the final stage of alcohol addiction which is
characterized by tolerance, that is, increased amount of alcohol Addiction has biological, family, psychological, and
consumption to get the same effect.[3] Excessive drinking makes social factors influencing its frequency, occurrence, and
it extremely difficult to adapt in the absence of alcohol, leading persistence.[13] The quality of interaction of family members
to withdrawal symptoms such as tremors, seizures, nausea, with toward the patient with ADS modulates the psychosocial
headache, sweating, increased heart rate, irritability, anxiety, cause for relapse.[8,14,15] It is the expressed emotion (EE) and
and insomnia causing extreme discomfort.[4,5] As a result of this its components such as criticality, hostility, and emotional
distress, alcohol becomes a central aspect of a person’s life.[5,6] overinvolvement are shown by the family members toward the
Recurrent use of alcohol hampers various aspects of a person’s patient with ADS.[14] These factors can potentially influence
life such as physical health, mental health, spiritual well‑being, the course of mental illness including alcohol used disorders
and social life (personal and interpersonal relationships,
Address for correspondence: Dr. Kannappa V. Shetty,
occupational, financial, and recreational activities).[2,7‑9] It also
Assistant Professor School of Social Work (SOSW) Section H, Block 15,
induces negative behaviors such as aggressiveness, resulting IGNOU, Maidan Garhi, New Delhi: 110068, India.
Email: [email protected]
Submitted: 26‑Jan‑2022 Revised: 01-Feb-2022 Accepted: 06-Feb-2022 Published: 21-Nov-2022

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DOI: How to cite this article: Shetty KV, Manikappa SK, Murthy S, Anjanappa J,
10.4103/aip.aip_14_22 Rawat VS. Expressed emotion among families of individuals with alcohol
dependence syndrome: A pilot study. Ann Indian Psychiatry 0;0:0.

© 2022 Annals of Indian Psychiatry | Published by Wolters Kluwer - Medknow 1

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Shetty, et al.: EE among families of individuals with ADS

after the treatment either positively or negatively.[16] Blaming

Table 1: Sociodemographics of patients with alcohol
the person and holding him accountable for the course of
dependence syndrome
illness, is an internal conflict resulting in hostility.[17,18] In
case of emotional overinvolvement, the family members tend Variable (n=31) Frequency (%)/mean±SD
to blame themselves for the patient’s condition and become Age 40.15±12.5
over concerned about the patient, which develops creates a Gender
feeling of pity, this in turn might foster stress in the patient, Male 25 (80.6)
Female 6 (19.4)
and the ability to process and manage the stressor decreases,
Education
resulting in relapse.[19] There is a dearth of research on EE in
Illiterate 15 (48.4)
the field of ADS in India. This article mainly intends to study
<10th 7 (22.6)
the EE of ADS, which will enable psychosocial interventions
PUC 8 (25.8)
for relapse prevention. Degree and above 1 (3.2)
Occupation
Materials and Methods Government job 3 (9.7)
Private job 20 (64.5)
This descriptive study recruited 31 male patients and
Business 7 (22.6)
their caregivers through convenient sampling method.
Home maker 1 (3.2)
The participants chosen were under treatment either at the
Annual income
hospital or at the rehabilitation center of a private tertiary care Up to 1 lakh 6 (19.4)
psychiatry center, Bengaluru. The sample mostly consisted of 1 lakh-3 lakhs 9 (29.0)
male patients who were consuming alcohol for at least 5 years, 3-5 lakhs 6 (19.4)
in the age range of 25–75 years. The caregivers of persons with 5 lakhs and above 8 (25.8)
ADS (consisting of parents, sisters, spouse, and children) who No income 2 (6.5)
were 18 years and above and the caregiver who were providing Marital status
care for more than 1 year were included in this study. The Single 4 (12.9)
caregivers who were fluent in Kannada, Telugu, or English Married 27 (87.1)
language were chosen, and the ICD‑10 criteria were used Family type
for diagnostic confirmation. Comorbid addictions including Nuclear 22 (71.0)
tobacco, cannabis, and other psychiatric problems were Joint 9 (29.0)
excluded for the study. The participants were interviewed by a SD: Standard deviation

semi‑structured questionnaire to collect the sociodemographic

data, and the Family Emotional Involvement and Criticism The analysis of the total score of the EE scale revealed a
Scale developed by Shields et al.[20] was administered to high mean score (42.06 ± 5.2) than the average score of
them for assessing EE. This scale measures two domains of the scale [Table 3]. The mean score of perceived criticism
EE‑perceived criticism and emotional involvement of the subscale was found to be higher (24.6 ± 1.94) than emotional
family members. Ethical permission was taken from the ethics overinvolvement (EOI) subscale (18 ± 4.48) among the ADS
committee of the institute, and informed consent was sought caregivers. The overall findings on this EE scale indicate that
from patients and their families after assuring confidentiality. there is high criticism among caregivers toward their family
The purpose, nature, and aim of the study were explained to the member who is suffering from ADS. However, there were
respondents. The data were entered into SPSS version 21, (IBM no gender, age, religion, family income, and caregiver type
United Kingdom Limited, Surrey, UK) and the analysis was differences on the scores of expression emotion.
done using the basic statistical operations such as frequency,
central tendency, Chi‑square, and ANOVA. Discussion
The present research aimed to study the EE among the family
Results members of persons with ADS. The findings revealed that,
Tables 1 and 2 depict the sociodemographic profile of the study there is high negative EE among the caregivers of persons with
participants. The mean age of the ADS patients was 40.8 years ADS. Among the subscales, perceived criticism was found to be
and caregivers were 45.1 years. There were more female higher than EOI subscale among the ADS caregivers. The overall
caregivers (67.7%) than male caregivers (32.3%). Majority findings on this EE scale indicate that there is high criticism among
of the caregivers (35.5%) were educated below matriculation, caregivers toward their family member who is suffering from
and most of the caregivers (61.3%) and patients (64.5%) were ADS and it may perpetuate frequent relapses as well as worsen
working as homemakers and private employees, respectively. the course of illness. The findings of the article corroborate with
Most of the caregivers’ (38.7%) were the wives of the patients. those of Atadokht et al.[21] and Hooley and Parker[22] that showed
Majority of the patients’ (29%) annual income ranged between a high level of EE by the caregivers toward their family member
1 and 3 lakhs. with substance used disorders and this may lead to relapse.

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Shetty, et al.: EE among families of individuals with ADS

as well as interactional processes within the family act as

Table 2: Sociodemographic variables of caregivers
influencing factors for EE.[28] Some studies have relatively
Variable Frequency (%)/mean±SD explored these components of EE for their potential to guide
Age 45.16±11.65 both the theory and clinical practice.[29]
Gender
Male 10 (32.3)
The study also showed that critical comments are very high
Female 21 (67.7) among the caregivers toward their family member with ADS.
Education The careful observations of straight interactions between
Illiterate 3 (9.7) caregivers and their patients lead to exchange of anger. This
<10th 11 (35.5) factor possibly contributes to physical violence from caregiver.
PUC 9 (29.0) Persons with ADS, who are not capable of getting up in the
Degree and above 8 (25.8) morning, who spend their entire earnings on alcohol, who do not
Occupation take care of their children and neglect family expenditure, and
Government job 2 (6.5) are irregular to work, the ones who do not wish to stop drinking
Private job 9 (29.0) alcohol, or who do not contribute in routine household tasks
Business 1 (3.2) are often criticized and labeled as alcoholic. However, persons
Home maker 19 (61.3) with ADS rarely get angered unless they feel triggered.[30] There
Income are many reasons for EE in the families of ADS such as faulty
Up to 1 lakh 4 (12.9) communication, social and cultural expectancies, caregivers’
1 lakh-3 lakhs 9 (29.0) burden and stress, lack of proper treatment for ADS, negative
3-5 lakhs 3 (9.7) lifestyles, and risk‑seeking personality of patients.[8,15]
5 lakhs and above 2 (6.5)
No income 13 (41.9) Gender‑wise analysis reveals that female patients had low (6,
Marital status 19.4%) participation in the study when compared to male
Single 1 (3.2) patients (25, 80.6%).[31] However, all the female patients
Married 28 (90.3) who received the treatment at our treatment center (private
Widow/widower 2 (6.5) psychiatry center) were from metropolitan city, belonged to
Relationship with the patient upper socioeconomic status, studied higher education, reported
Wife 12 (38.7) history of alcohol in multiple family members, had good social
Mother 8 (25.8) support, and noticed less stigma in receiving treatment for
Father 1 (3.2) alcohol problem.
Sister/brother 3 (9.7)
Others 3 (9.7) This study was skewed toward males with alcohol dependence.
Husband 4 (12.9) Both on account of the fact that alcohol use is more prevalent
SD: Standard deviation among males and due to practical difficulties, more male
patients with ADS were part for the study. Another limitation
was sample size being restricted to a small number. Some
Table 3: Mean score of Expressed Emotion Scale among other limitations of the study were lack of control group, single
caregivers of persons with alcohol dependence syndrome location, convenient sampling technique, and lack of blinding
EOI PC Total EE in the assessment.
n 31 31 31
Mean±SD 18.00±4.479 24.06±1.94 42.06±5.27 Conclusion
SD: Standard deviation, EOI: Emotional over‑involvement, PC:
Perceived criticism, EE: Expressed emotion This study highlights the importance of addressing high EE
among the family members of persons with ADS in the Indian
The significance of EE is well established through many context and to devise a psychosocial intervention program
studies that have looked at EE as a theoretical construct that is exclusively based on development of skills of the
caregivers, to make them partners with treatment providers
and as a robust predictor of relapse in severe psychiatric
to help with the treatment process and to achieve the speedy
illnesses.[23] Researchers also have found that the family
recovery and to prevent further relapse of the individuals
environment plays a vital role in influencing the onset and with ADS.
course of severe mental disorders.[24] A cross‑sectional
connection between EE and family burden has been Acknowledgments
identified. [25] EE is one of the by‑products of family Authors would like to thank Dr. Pratima Murthy (Professor
environment which would adversely affect the course and of Psychiatry, NIMHANS, Bengaluru) for her insightful
suggestions that helped to improve the manuscript.
outcome.[26,27] Family’s response to mental illness varies
according to their culture, region, and the language. The Financial support and sponsorship
cultural factors, family dynamics, and family expectations Nil.

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Shetty, et al.: EE among families of individuals with ADS

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