Role of Expressed Emotion in Family Psychopathology

aggressive parent
aggressive parent
Investigators examined the role of family psychopathology in parental expressed emotions attitudes in a group of adolescents with bipolar disorder.

Higher levels of expressed emotion (EE) are associated with susceptibility to affective psychopathology in parents and a higher familial loading for depression and bipolar disorder, according to study results published in Psychiatry Research.

Researchers examined the role of family psychopathology in parental EE attitudes, especially as it relates to parent/caregiver characteristics. A total of 95 parents and their 86 offspring were recruited as part of a 3-site randomized trial of family-focused treatment plus pharmacotherapy in youth (age 12 to 18) with bipolar I or II disorder who had experienced a manic, hypomanic, depressive, or mixed episode within the 3 months leading up to enrollment in the study; at least moderately severe hypomanic or depressive symptoms in the previous month; and a willingness to undergo pharmacotherapy for the 2-year duration of the study.

Youth diagnoses were determined using the Kiddie Schedule for Affective Disorders and Schizophrenia, Present and Lifetime Version (KSADS-PL) and a separate interview with a board-certified psychiatrist. Current severity of manic and depressive symptoms was rated using the 6- or 7-point K-SADS Mania Rating Scale and Depression Rating Scale, respectively. Cross-site reliability of the rating scales was 0.89 for the Depression and 0.81 for the Mania Rating Scales. EE status was coded from Five Minute Speech Samples (FMSS) of the parents. Reliability (ICC) on EE status between co-raters across 10 FMSS was 0.95. Parents’ concurrent levels of emotional distress (past-week levels of depression, anxiety, anger/hostility, interpersonal sensitivity) were assessed using the Symptom Checklist-90-Revised. The lifetime presence of familial major depressive, bipolar, and anxiety disorders was gathered using the Family History Screen. Each parent was rated as having or not having a personal history of each mood disorder.

More past-week symptoms of depression (t(94) = 3.31, P =.001), anxiety (t(94) = 3.73, P < .001), and anger/hostility ((t(94)=3.03, P =.003) were reported in parents with high EE than parents with low EE.  No differences in levels of interpersonal sensitivity were determined (t(94) = 1.48, P =.14).

Neither group differed significantly in the probability of having a lifetime diagnosis of major depressive disorder (χ2(1)=2.66, P =.10), bipolar disorder (χ2(1)=1.03, P =.31), or anxiety disorder (X2(1)=1.62, P =.20) on the Family History Screen. In addition, parents with high EE had higher familial loadings of depressive (t(70)=2.12, P =.03) and manic/hypomanic syndromes (t(70) = 2.01, P =.04), but not anxiety syndromes (t(70)=1.86, P =.07).  When entered into individual regression models, both total current emotional distress and family history of depressive and manic/hypomanic syndromes significantly predicted EE status. When considering both variables together, only current emotional distress was significant (χ2(1)=3.99, P =.046).

Mood symptom severity in adolescents was not associated with the classification of parental EE. The severity of offspring’s Depression Rating Scale and Mania Rating Scale scores did not differ from the K-SADS in parents with low and high EE.

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The researchers noted that because the findings are cross-sectional causality cannot be inferred, although the findings are consistent with an EE diathesis-stress conceptualization. Also, family history may be limited in its ability to detect psychiatric histories of parents’ relatives. The similar socioeconomic backgrounds of the youths in the sample may also have affected the outcomes. Finally, they noted the possibility of the FMSS under-identifying high EE caregivers.

The ivestigators concluded that “several patient and caregiver characteristics have been identified as correlates of high or low EE attitudes in caregivers.” Emotional distress in parents and a family history of depressive and bipolar disorder relate to EE levels of parents of adolescents with bipolar disorder I or II. With this in mind, family interventions for adolescent bipolar disorder are a promising strategy for reducing stress in a high EE environment.


Millman Z B, Weintraub M J, Miklowitz D J. Expressed emotion, emotional distress, and individual and familial history of affective disorder among parents of adolescents with bipolar disorder. Psychiatry Research. 2018;270:656-660.