As EE concept was developed by George Brown and his associated in the Institute of Psychiatry in London in the 1950s (Brown , Carstirs & Topping, 1958).
Browns studies focused on the relation between family variables and the likelihood of relapse on the part of persons with schizophrenia who had recently been released from the hospital. Those investigators found that patients who went to live with family members who were highly emotionally involved were much more likely to relapse than those patients who went to families who were less hostile or who exhibited less EE. There relationship between emotional involvement and relapse was not related to the severity of symptoms at the time of discharge.
High EE was defined as involving three factors:
Statements of resentment, disapproval, or dislike, and any comments expressed with critical inotation that is a critical tone, pitch, rhythm or intensity in their voice.
Hostile remarks indicating personal criticism
Emotional over involvement, constant worries about minor matters, overprotective attitudes, intrusive behavior.
Additionally warmth expressed in terms of positive comments and voice tone, appeared to be added protection for persons discharged to low EE environment and dissatisfaction even when not expressed in an critical or hostile manner, appeared to increase relapse risk in high EE households.
People with schizophrenia are indeed very sensitive to hostile criticism and other forms of expressed emotions. Such people need to avoid places, persons and things likely to encounter EE or learn communication skills to encounter it.
EE is made up of a number of dimensions:
The frequency of critical comments, hostility (a 4 point scale), marked emotional involvement (a 6 point scale), warmth (a 6 point scale), and the frequency of positive remarks. From these ratings high and low EE is calculated. The high EE involves 6 or more critical comments, one or more score on hostility, three or more on hostility.
There is strong association between relapse and living with high EE as studied by Brown et al in 1972, Moline in 1985, Wig in 1987 and Vaughn in 1988. The Affective Style coding system measured high EE exhibited more negatively charged emotional verbal behavior and critical comments during interaction than low EE.
It is possible to reduce relapse rates through family intervention. Klerman's conclusion ell that intensive individual psychotherapy of schizophrenia has less evidence for its utility than that of efficiency of family therapy in reducing intra-familial EE.
Successful intervention studies include an educational component i.e.
providing information to the relative about the illness.
How to manage the patient at home
Tarrier and Barrowclough (1986) suggested that are two models of information-giving.
It implies that a lack of information results in detrimental behavior and providing that information will eliminate this behavior.
Suggests that people produce their own explanations of illness and that information provided by professionals will be assimilated, organized, and possibly rejected on the basis of the person's own perceptions and explanations.
Barrowclough et al (1987) produced evidence that education of EE to relatives is more likely to be productive if it occurs earlier when the patient is in acute form. Therefore the education will aim at reducing stress in the family enviornment.
The goal of interventions aimed at High EE families is to reduce the EE status of the relatives from High to Low EE, because High EE relatives are associated with higher relapse rates. Changes in EE in successful intervention groups has been provided by three studies (Leff et al, 1982; Hogarty 1986; Tarrier, Barrowclough, Vaughn 1988). Hogarty provided evidence for the mediating role of EE in that there were no relapses in any family where the relatives changed from High to Low EE. Barrow showed that group differences could not be explained by medication dosages or by contact to other psychiatric services. Some role of EE in relapse comes from psychological studies. Tarrier (1987) found that patients whose relatives remained High EE over 9 months sowed greater levels of arousal and reactivity than patients whose relatives changed from High to Low EE.
A schizophrenic episode is characterized by
Increase in general arousal level.
Hyperactivity to social stressors.
Patients remaining with High EE relatives show decrease in reactivity and increased level of arousal in their relative's presence.
The aim of intervention is to reduce stress experienced by the patient in his enviornment. It can be done by:
giving social skill training to the patient to respond appropriately to the stressful surrounding
Tendency to become high EE psychologist
Frequent application of coping strategies in the hospital
Lack of economic and material resources of the family
Lack of training
Lack of knowledge of behavioral principles and methods