Original Article

Expressed Emotions in Patients with Obsessive

Compulsive Disorder: A Case Control Study

Sateesh R. Koujalgi, Raghavendra B. Nayak, Nanasaheb M. Patil, Sameeran S. Chate

ABSTRACT
Background: Expressed emotion (EE) is the attitude that the relatives show towards the illness and the person. EE is
identified as a direct factor in the relapse of patients with psychological disorders. Literature on EE in anxiety disorders
is limited. Role of EE in obsessive compulsive disorder (OCD) may help in better understanding of the role of social
factors in OCD. Aim: To compare EE in patients with OCD and compare with controls. Materials and Methods: The sample
included 30 cases and 30 age and sex matched controls. The patients were diagnosed as having OCD using International
Classification of Diseases-10 Diagnostic Criteria for Research (ICD-10 DCR) criteria. Yale-Brown Obsessive Compulsive
Scale (Y-BOCS) was used to assess severity of OCD among patients. General health questionnaire (GHQ) was used to rule
out any psychiatric disorder among control population. EE was assessed in cases and controls using Family Emotional
Involvement and Criticism Scale (FEICS). Chi-square test and t-test were used to assess the difference between two groups.
Results: OCD patients in comparison controls had significantly increased total FEICS score (P = 0.001). There was an
increase in both subscales of perceived criticism (PC) with P = 0.001 and emotional involvement (EI) with P = 0.001 in
patients with OCD than controls. Conclusion: EE are significantly increased in patients with OCD. EE should be assessed
regularly in patients with OCD.

Key words: Emotional involvement, expressed emotions, obsessive compulsive disorder, perceived criticism

INTRODUCTION including OCD. One factor that contributes to such a

relapse is expressed emotions (EE) from the relatives
Obsessive compulsive disorder (OCD) is anxiety that they are living with after initial treatment.[1] EE is
disorder which usually has chronic and follows a the attitude that the relatives show towards the illness
waxing and waning course. A majority of patients who and the person. Patients undergo criticism from relatives
are diagnosed with psychological disorders go through for not having adequate occupational and interpersonal
rehabilitation during the process of treatment. Relapses functioning during the process of recovery.
and recurrences are common in psychological disorders
Various studies have explored the role of psychosocial
Access this article online factors in OCD.[2] An EE is a concept developed to
Quick Response Code quantify the impact of family factors in schizophrenic
Website:
relapse.[3] Families are also pathologically involved
www.ijpm.info
with OCD patients. [4] Initially the concept and
measurement of the EE within families were developed
DOI: for use in schizophrenia. They were subsequently used
10.4103/0253-7176.130972 for a number of physical and psychiatric conditions,
ranging from dementia to diabetes and Parkinson’s

Department of Psychiatry, Karnataka Lingayat Education University's Jawaharlal Nehru Medical College, Belgaum,
Karnataka, India

Address for correspondence: Dr. S. R. Koujalgi

Department of Psychiatry, Karnataka Lingayat Education University’s Jawaharlal Nehru Medical College, Nehru Nagar, Belgaum - 590 010,
Karnataka, India. E-mail: [email protected]

138 Indian Journal of Psychological Medicine | Apr - Jun 2014 | Vol 36 | Issue 2
 Koujalgi, et al.: Expressed emotions in patients with OCD

disease. Assessment of EE has played a major role in numbered items and the EI subscale score is obtained
the development and evaluation of social treatments of from the total of odd numbered items of FEICS. General
schizophrenia.[5] The family’s EE has been shown to be health questionnaire (GHQ) was used to screen for
predictive of outcome in mental and physical illnesses any psychiatric morbidity among control population.
in a variety of cultural settings.[6] Statistical analysis was done using Statistical Packages
for Social Sciences (SPSS) version 13 software.
Studies on EE are few among Indian population. High Chi-square test and t-tests were used to assess the
EE was found to predict relapse even in Indian patients difference between two groups, P < 0.05 is considered
with schizophrenia.[7] There is a single cohort study as statistically significant.
from India on EE in OCD.[8] In view of limited data
on EE in OCD we designed this study to compare the RESULTS
EE in OCD patient and normal controls.
Sociodemographic details among groups are described
MATERIALS AND METHODS in Table 1. The mean age of patients with OCD was
25.57 ± 4.79 and 26.50 ± 4.83 years in control group.
The study sample included 30 patients with OCD and Both groups had 21 males (70.0%) and nine females
30 normal individuals in the control group. Purposive (30.0%). There was no difference among two groups
sampling method was used in this study. The samples in educational status and socioeconomic status. There
were collected from psychiatry outpatient department. was significant difference (P = 0.004) of marital status
The patients fulfilling International Classification of among two groups. More of OCD patients were single
Diseases-10 Diagnostic Criteria for Research (ICD-10 and individuals in control group were married. OCD
DCR) for OCD were included as cases. Patients with patients lived in nuclear family than control group
age range of 18-60 years who gave informed consent (P = 0.044). Most of the OCD patients were unemployed
for study were taken up for the study. Patients were
excluded if they were found to have organic mental Table 1: Comparison of the sociodemographic variables
disorder or other comorbid psychiatric disorder Variables OCD group Control group t/c2 P-value
(except for depression). Thirty normal individuals (n=30) (n=30)
were matched for age and sex and who had no history mean±S.D mean±S.D
of psychiatric disorder were included as control group. Age (years) 25.57±4.79 26.50±4.83 −0.752 0.455
Sex
A semi-structured proforma was prepared for this study, Male 21 (70.0%) 21 (70.0%) 0.000 1.000
which included registration number, age, sex, education, Female 9 (30.0%) 9 (30.0%)
marital status, domicile, mother tongue, type of family, Education
Primary 2 (6.7%) 1 (3.3%) 4.762 0.313
occupation, and family income. Each patient was
High school 3 (10.0%) 9 (30.0%)
administered with Yale-Brown Obsessive Compulsive
PUC 12 (40.0%) 9 (30.0%)
Scale (Y-BOCS).[9] This scale is used to assess the UG 10 (33.3%) 10 (33.3%)
severity of OCD. Family Emotional Involvement and PG 1 (3.3%) 3 (10.0%)
Criticism Scale (FEICS)[10] was used to assess the level Marital status
of EE in OCD group and same was administered to Single 22 (73.3%) 11 (36.7%) 8.148 0.004
normal controls group. The FEICS is a self-reporting Married 8 (26.7%) 19 (63.3%)
scale to measure EE. The FEICS has two subscales: Type of family
Perceived criticism (PC) and intensity of emotional Nuclear 29 (96.7%) 24 (80.0%) 4.043 0.044
involvement (EI). These two factors are analogous to Non-nuclear 1 (3.3%) 6 (20.0%)
critical comments and emotional overinvolvement, Occupation
the two main factors that are measured through the Working 7 (23.3%) 27 (90.0%) 27.149 <0.001
Nonworking 23 (76.7%) 3 (10.0%)
Camberwell Family Interview.[11] Cronbach’s alpha for
Family income
both the subscales was 0.74-0.82. Confirmatory factor
500-1,000 1 (3.3%) 0 (0%) 1.267 0.867
analysis showed that each item loaded on its proposed 1,001-3,000 3 (10.0%) 4 (13.3%)
factor and not with the other factor. The subscales 3,001-10,000 9 (30.3%) 9 (30.3%)
exhibited correlations and partial correlations with 50,001-10,000 10 (33.3%) 11 (36.7%)
various scales, such as the Family Adaptability and >10,001 7 (23.3%) 6 (20.0%)
Cohesion Evaluation Scales,[12] Interpersonal Support Domicile
Evaluation List,[13] and Symptom Checklist-90 (SCL-90). Urban 30 (100%) 30 (100%) — —
Rural 0 0
The scale consists of 14 items marked 1 to 5. The OCD – Obsessive compulsive disorder, PUC – Pre-university college,
PC subscale score is obtained from the total of even UG – Under graduate, PG – Post graduate

Indian Journal of Psychological Medicine | Apr - Jun 2014 | Vol 36 | Issue 2 139
 Koujalgi, et al.: Expressed emotions in patients with OCD

(P < 0.001). All the cases and controls were from urban However, both groups were dominated by nuclear
background. The mean scores of Y-BOCS [Table 2] families. As a result of industrialization, there is an
of patients with OCD are 12.87 ± 3.94 (obsessions), increasing trend towards changing to nuclear families.
11.97 ± 3.37 (compulsions), and 25.37 ± 6.96 (total Earlier observations show that the neurotic disorder
score). EE were assessed in both the groups using FEICS occurs more in nuclear families, this is due to the joint
[Table 3]. The mean score of PC in patients with OCD family system breaking up and this transitional period
was 24.53 ± 5.89 and control group had 15.10 ± 0.48 in the social life was responsible for higher neurotic
with P = 0.001. The mean scores of EI in patients disturbances.[17,18] There was significant difference
with OCD was 25.33 ± 4.59 and control group had between two groups with regard to occupation. Hollander
15.07 ± 0.45 with P = 0.001. The overall mean FEICS et al.,[19] reported that 41% were unable to work due to
scores were 50.70 ± 6.71 and 30.17 ± 0.59 for OCD OCD symptoms, with an average loss of 2 years of wage.
group and control group, respectively; this was also There was no difference in family income among two
statistically significant (P = 0.001) between two groups. groups. This could be because all the samples were from
an urban background and most of the key caregivers were
DISCUSSION either skilled government employees or businessmen.

This was a case control study to find the severity of Among the five EEs; critical comments, hostility, and
EE among OCD patients in comparison to normal emotional over involvement have been shown to be the
controls. There are no studies on EE in normal adult most predictive of relapse.[20] The FEICS was used to
general population. However, high EE during childhood assess EE. Mean scores of PC, EI, and total FEICS were
is predictive of adolescent depressive, aggressive, and significantly more in patients with OCD (P = 0.001
delinquency symptoms.[14] This suggest that even in a for all the three areas). The present study indicates
family without any kind illness may have some baseline high level of EE in OCD families. Both PC and EI
EE which may or may not lead to future psychological seem to indicate significant family pathology. There is
symptoms. There were more male patients than females. a single Indian study[8] on EE in OCD patients with
OCD involving Indian patients had reported similar similar findings. This was a cohort study and FEICS
findings with males constituting 67.30% of the sample scores were compared to normative data suggested
and female only 32.70% of the sample.[15] There was by the developer of the scale. This study included 35
significant difference between two groups with regards patients with OCD and patients were assessed for
to marital status. A study reported that female OCD EE using FEICS. The Y-BOCS was used to measure
patients are as likely to be married as their nonpsychiatric severity of obsessive compulsive symptoms. The OCD
counterparts, but male OCD patients are more likely patients had an increased score on EE with an increase
to remain single.[16] This difference may be due to the in both subscale of PC and EI. There was no significant
early onset of OCD in males and it is likely that people correlation between scores on these scales and Y-BOCS
with OCD choose not to get married, as it can lead to duration of illness or age. Patients are more likely to
adjustment problem for the partner and for themselves relapse when there is high EE present in their living
to adjust in the marital life. There was a significant environment. The patient falls back into a cycle of
difference between the two groups in the type of family. relapse and rehabilitation. Educating the family about
mental illness is one way that EE can become lower
Table 2: Y-BOCS severity rating of OCD patients and no longer an issue. Knowledge of the disorder will
Variable (n=30) Mean±SD help them to understand and recognize certain behavior
Obsession 12.866±3.936 and adjust to them. In a study on model of relapse in
Compulsion 11.966±3.368 OCD, it is hypothesized that relapse is likely when
Total 25.366±6.960 patients lack coping skills and social support or when
Y-BOCS-Yale-Brown Obsessive Compulsive Scale, OCD – Obsessive they experience high EE.[21]
compulsive disorder

Table 3: Rating of EE using FEICS scale

CONCLUSION
Variables OCD Control t P-value
group group The present study has shown that patient with OCD
Mean±SD Mean ± SD experienced considerable degree of EE. This has
Perceived criticism (PC) 24.53±5.89 15.10±0.48 8.746 0.001 important implication for management of patient with
Emotional involvement (EI) 25.33±4.59 15.07±0.45 12.196 0.001 OCD. For psychiatry professionals dealing with OCD,
Total score 50.70±6.71 30.17±0.59 16.705 0.001 an awareness of the nature of the problem faced by
EE – Expressed emotion, FEICS – Family Emotional Involvement and the patient and family will help them in dealing more
Criticism Scale, OCD – Obsessive compulsive disorder effectively with the patient and his family.

140 Indian Journal of Psychological Medicine | Apr - Jun 2014 | Vol 36 | Issue 2
 Koujalgi, et al.: Expressed emotions in patients with OCD

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