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 Table of Contents  
Year : 2022  |  Volume : 6  |  Issue : 4  |  Page : 374-377

Expressed emotion among families of individuals with alcohol dependence syndrome: A pilot study

1 School of Social Work, Indira Gandhi National Open University (IGNOU), New Delhi, India
2 Department of PSS, NIMHANS, Bengaluru, Karnataka, India
3 Department of Psychology, Christ University, Bengaluru, Karnataka, India
4 Department of Psychiatry, Abhaya Hospital, Bengaluru, Karnataka, India
5 Department of Psychiatry, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Submission26-Jan-2022
Date of Decision01-Feb-2022
Date of Acceptance06-Feb-2022
Date of Web Publication21-Nov-2022

Correspondence Address:
Dr. Kannappa V Shetty
Assistant Professor, School of Social Work (SOSW), Section H, Block 15, IGNOU, Maidan Garhi, New Delhi, 110068
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aip.aip_14_22

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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

How to cite this article:
Shetty KV, Manikappa SK, Murthy S, Anjanappa J, Rawat VS. Expressed emotion among families of individuals with alcohol dependence syndrome: A pilot study. Ann Indian Psychiatry 2022;6:374-7

How to cite this URL:
Shetty KV, Manikappa SK, Murthy S, Anjanappa J, Rawat VS. Expressed emotion among families of individuals with alcohol dependence syndrome: A pilot study. Ann Indian Psychiatry [serial online] 2022 [cited 2023 Mar 26];6:374-7. Available from: https://www.anip.co.in/text.asp?2022/6/4/374/361670

  Introduction Top

In India, alcohol consumption has increased drastically from past two decades, and more than half of individuals are in the category of hazardous drinking.[1],[2] Alcohol dependence syndrome (ADS) is the final stage of alcohol addiction which is characterized by tolerance, that is, increased amount of alcohol consumption to get the same effect.[3] Excessive drinking makes it extremely difficult to adapt in the absence of alcohol, leading to withdrawal symptoms such as tremors, seizures, nausea, headache, sweating, increased heart rate, irritability, anxiety, and insomnia causing extreme discomfort.[4],[5] As a result of this distress, alcohol becomes a central aspect of a person's life.[5],[6] Recurrent use of alcohol hampers various aspects of a person's life such as physical health, mental health, spiritual well-being, and social life (personal and interpersonal relationships, occupational, financial, and recreational activities).[2],[7],[8],[9] It also induces negative behaviors such as aggressiveness, resulting in recurrent arguments with spouse, children, parents, and other family members. This can eventually lead to violence, withdrawal from household and work, risk-taking attitudes such as drunken driving, getting arrested for alcohol related disorderly conduct, and causing recurrent legal issues.[10],[11],[12]

Addiction has biological, family, psychological, and social factors influencing its frequency, occurrence, and persistence.[13] The quality of interaction of family members with toward the patient with ADS modulates the psychosocial cause for relapse.[8],[14],[15] It is the expressed emotion (EE) and its components such as criticality, hostility, and emotional overinvolvement are shown by the family members toward the patient with ADS.[14] These factors can potentially influence the course of mental illness including alcohol used disorders after the treatment either positively or negatively.[16] Blaming the person and holding him accountable for the course of illness, is an internal conflict resulting in hostility.[17],[18] In case of emotional overinvolvement, the family members tend to blame themselves for the patient's condition and become over concerned about the patient, which develops creates a feeling of pity, this in turn might foster stress in the patient, and the ability to process and manage the stressor decreases, resulting in relapse.[19] There is a dearth of research on EE in the field of ADS in India. This article mainly intends to study the EE of ADS, which will enable psychosocial interventions for relapse prevention.

  Materials and Methods Top

This descriptive study recruited 31 male patients and their caregivers through convenient sampling method. The participants chosen were under treatment either at the hospital or at the rehabilitation center of a private tertiary care psychiatry center, Bengaluru. The sample mostly consisted of male patients who were consuming alcohol for at least 5 years, in the age range of 25–75 years. The caregivers of persons with ADS (consisting of parents, sisters, spouse, and children) who were 18 years and above and the caregiver who were providing care for more than 1 year were included in this study. The caregivers who were fluent in Kannada, Telugu, or English language were chosen, and the ICD-10 criteria were used for diagnostic confirmation. Comorbid addictions including tobacco, cannabis, and other psychiatric problems were excluded for the study. The participants were interviewed by a semi-structured questionnaire to collect the sociodemographic data, and the Family Emotional Involvement and Criticism Scale developed by Shields et al.[20] was administered to them for assessing EE. This scale measures two domains of EE-perceived criticism and emotional involvement of the family members. Ethical permission was taken from the ethics committee of the institute, and informed consent was sought from patients and their families after assuring confidentiality. The purpose, nature, and aim of the study were explained to the respondents. The data were entered into SPSS version 21, (IBM United Kingdom Limited, Surrey, UK) and the analysis was done using the basic statistical operations such as frequency, central tendency, Chi-square, and ANOVA.

  Results Top

[Table 1] and [Table 2] depict the sociodemographic profile of the study participants. The mean age of the ADS patients was 40.8 years and caregivers were 45.1 years. There were more female caregivers (67.7%) than male caregivers (32.3%). Majority of the caregivers (35.5%) were educated below matriculation, and most of the caregivers (61.3%) and patients (64.5%) were working as homemakers and private employees, respectively. Most of the caregivers' (38.7%) were the wives of the patients. Majority of the patients' (29%) annual income ranged between 1 and 3 lakhs.
Table 1: Sociodemographics of patients with alcohol dependence syndrome

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Table 2: Sociodemographic variables of caregivers

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The analysis of the total score of the EE scale revealed a high mean score (42.06 ± 5.2) than the average score of the scale [Table 3]. The mean score of perceived criticism subscale was found to be higher (24.6 ± 1.94) than emotional overinvolvement (EOI) subscale (18 ± 4.48) among the ADS caregivers. The overall findings on this EE scale indicate that there is high criticism among caregivers toward their family member who is suffering from ADS. However, there were no gender, age, religion, family income, and caregiver type differences on the scores of expression emotion.
Table 3: Mean score of Expressed Emotion Scale among caregivers of persons with alcohol dependence syndrome

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  Discussion Top

The present research aimed to study the EE among the family members of persons with ADS. The findings revealed that, there is high negative EE among the caregivers of persons with ADS. Among the subscales, perceived criticism was found to be higher than EOI subscale among the ADS caregivers. The overall findings on this EE scale indicate that there is high criticism among caregivers toward their family member who is suffering from ADS and it may perpetuate frequent relapses as well as worsen the course of illness. The findings of the article corroborate with those of Atadokht et al.[21] and Hooley and Parker[22] that showed a high level of EE by the caregivers toward their family member with substance used disorders and this may lead to relapse.

The significance of EE is well established through many studies that have looked at EE as a theoretical construct and as a robust predictor of relapse in severe psychiatric illnesses.[23] Researchers also have found that the family environment plays a vital role in influencing the onset and course of severe mental disorders.[24] A cross-sectional connection between EE and family burden has been identified.[25] EE is one of the by-products of family environment which would adversely affect the course and outcome.[26],[27] Family's response to mental illness varies according to their culture, region, and the language. The cultural factors, family dynamics, and family expectations as well as interactional processes within the family act as influencing factors for EE.[28] Some studies have relatively explored these components of EE for their potential to guide both the theory and clinical practice.[29]

The study also showed that critical comments are very high among the caregivers toward their family member with ADS. The careful observations of straight interactions between caregivers and their patients lead to exchange of anger. This factor possibly contributes to physical violence from caregiver. Persons with ADS, who are not capable of getting up in the morning, who spend their entire earnings on alcohol, who do not take care of their children and neglect family expenditure, and are irregular to work, the ones who do not wish to stop drinking alcohol, or who do not contribute in routine household tasks are often criticized and labeled as alcoholic. However, persons with ADS rarely get angered unless they feel triggered.[30] There are many reasons for EE in the families of ADS such as faulty communication, social and cultural expectancies, caregivers' burden and stress, lack of proper treatment for ADS, negative lifestyles, and risk-seeking personality of patients.[8],[15]

Gender-wise analysis reveals that female patients had low (6, 19.4%) participation in the study when compared to male patients (25, 80.6%).[31] However, all the female patients who received the treatment at our treatment center (private psychiatry center) were from metropolitan city, belonged to upper socioeconomic status, studied higher education, reported history of alcohol in multiple family members, had good social support, and noticed less stigma in receiving treatment for alcohol problem.

This study was skewed toward males with alcohol dependence. Both on account of the fact that alcohol use is more prevalent 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 other limitations of the study were lack of control group, single location, convenient sampling technique, and lack of blinding in the assessment.

  Conclusion Top

This study highlights the importance of addressing high EE among the family members of persons with ADS in the Indian context and to devise a psychosocial intervention program that is exclusively based on development of skills of the caregivers, to make them partners with treatment providers to help with the treatment process and to achieve the speedy recovery and to prevent further relapse of the individuals with ADS.


Authors would like to thank Dr. Pratima Murthy (Professor of Psychiatry, NIMHANS, Bengaluru) for her insightful suggestions that helped to improve the manuscript.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3]


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