Expressed Emotions in Patients with Mild to Moderate Ulcerative Colitis: A Descriptive Study

Abstract

Background

Ulcerative colitis (UC) is an autoimmune disease with phases of relapse and remission. Empirical data shows that expressed emotion (EE) is one of the important stressors which shows a direct association with the recurrence of illness. Though a huge amount of research has been done on mental illness, in this research, it has been used to see how this construct effects people with UC.

Purpose

To assess the level of EE among patients with mild-to-moderate UC. It also aims to find whether there is a significant difference among UC patients with respective to demographic variables like age, gender, education, marital status and socio-economic status (SES).

Methods

It followed a quantitative approach and descriptive survey research design. The sample size was 100, including both males and females (50 each) in the age group of 30–50 years. The tools used were the family emotional involvement (EI) and criticism scale (FEICS) to quantify the perceived criticism (PC) and EI. Inferential statistics and a chi-square test were used.

Results

UC patients showed a mean PC score of 14.87 out of 28 and a mean EI score of 17.24 out of 28. UC patients had a total mean score of 32.11, which depicted high EE. There was no significant association found between the demographic variables in this study and EE.

Conclusion

The present findings show that patients with UC show moderate PC but high EI. For UC, the family environment can be improved by better interventions in the form of family counselling and psychoeducation. Fostering coping skills, stress management and effective communication in families will help in emotional regulation among patients of UC.

Introduction

Expressed emotion (EE) is a pivotal concept in the realm of psychiatry, denoting the level of emotional expression exhibited by family members towards an individual with a psychiatric disorder. EE, coined by Brown and Rutter in the 1960s, comprises critical comments, emotional overinvolvement and positive remarks. ¹ Critical comments entail negativity, while emotional over-involvement involves excessive, intrusive behaviour. Positive remarks are supportive and empathetic expressions. Research has shown that EE is pivotal in comprehending and managing psychological disorders like schizophrenia,^{2, 3} bipolar disorder, ⁴ eating disorders,^5–7 and depression. ⁸ Schizophrenia has been extensively studied in this context. High EE in families correlates with higher relapse risk and poorer outcomes for individuals with schizophrenia. ⁹ Living in a high-EE environment can worsen symptoms and hinder effective coping. EE’s impact on psychiatric disorders is a well-researched field.

Amaresha and Venkatasubramanian (2012) provided a comprehensive overview, highlighting EE’s multifaceted nature and impact on psychosocial functioning. ¹⁰ Bebbington and Kuipers’ (1994) analysis affirmed EE’s predictive utility in diverse contexts. ¹¹ In mood disorders, high EE worsens depression and treatment outcomes. ¹² Butzlaff and Hooley (1998) established a strong link between EE and psychiatric relapse. ¹³ Mino et al. (2001) reinforced this in a Japan-based study, highlighting EE’s cross-cultural relevance. ¹⁴ Weintraub et al.’s (2021) speech analysis using machine learning offered a promising tool for classifying EE. ¹⁵ EE also influences eating disorders, as shown by Duclos et al. (2012) ¹⁶ and Rienecke (2018). ¹⁷ Van Furth et al. (1996) emphasised EE’s role in adolescent eating disorder treatment outcomes. ¹⁸ These studies emphasise the crucial role of EE in understanding and managing these disorders. Understanding emotional states helps predict relapses and adjust interventions.

Not much research has been done on EE and ulcerative colitis (UC). As UC is chronic in nature, there is disturbance in routine activities, and hence, these patients experience mental symptoms like depression and anxiety.^19–21 A possible basis for this is the gut-brain bidirectional communication. ²² People with UC have inflammation in the colon and rectum. It affects millions of individuals all over the world and tremendously impacts patients’ quality of life. ²³ Alongside the physical symptoms, UC often takes a toll on patients’ mental and emotional well-being. ²⁴ The emotional response of patients with UC has already gained attention in recent research as a crucial aspect of understanding and managing this debilitating condition. Numerous studies have explored the role of emotions in UC patients. Grace, Wolf and Wolff’s 1950 study revealed a significant link between emotional distress and UC exacerbation. ²⁵ This seminal work emphasised considering emotional factors in UC management and advocated for psychosocial interventions in patient care. By acknowledging the impact of emotions, this study propelled a more comprehensive approach to treating and supporting those with UC.

The UC-LIFE Survey examined the emotional impacts of UC on 700+ outpatients in Spain. ²⁶ Results revealed significant strain—anxiety, depression and frustration. Concerns about diminished quality of life were expressed, emphasising the need for emotional well-being in UC care. High stress levels and poor coping worsened UC symptoms, while perceived support lessened severity. Anxiety often accompanies UC, exacerbating its course. ²⁶ Chen et al.’s (2019) study uncovers connections between gut microbiota, metabolomics and proteomics in active UC, strongly correlated with depression and anxiety. ²⁷ Gracie et al. (2018) highlight the bidirectional relationship between depression and UC, emphasising how stressors worsen UC. ²⁸ Hence, the current research aims to understand EE in patients with UC. We hypothesise that UC patients would exhibit higher levels of EE.

Method

Design

A quantitative approach was followed with a descriptive survey research design.

Sample

The study encompassed a sample size of 100 individuals with UC (50 males and 50 females) from the Nagpur region. The age group was between 30 and 50 years, representing a diverse socio-economic spectrum encompassing individuals from all strata of society. Moreover, the sample was deliberately selected to include individuals from both urban and rural backgrounds, ensuring a comprehensive representation of various living conditions. Inclusion criteria included persons receiving the diagnosis of UC based on endoscopic investigation and histological criteria. Persons with mild-to-moderate disease activity of UC were taken. Mild-to-moderate UC is defined as patients with less than four to six bowel movements every day, mild or moderate bleeding per rectum, no constitutional symptoms and showing low overall inflammatory burden. ²⁹ Patients with multiple medical issues and major psychiatric disorders were excluded from the study.

Test Details

The Family Emotional Involvement and Criticism Scale (FEICS)-II was used. This scale was developed by Cleveland G. Shields and is a crucial tool for gauging EE in family dynamics. It’s a self-report scale assessing emotional involvement (EI) and criticism within familial relationships. FEICS-II demonstrates high reliability (Cronbach’s alpha > 0.80) and robust concurrent validity (P < .001). This questionnaire contains 14 belief statements related to their family experiences. Responses were given on a five-point scale from ‘Almost Never’ to ‘Almost Always’, with an emphasis on no right or wrong answers, fostering an open and supportive research environment.

Procedure

In this research, 100 individuals participated in a pencil and paper test. The study focused on ‘Expressed Emotion in Persons with mild-to-moderate Ulcerative Colitis’. Participants were informed about the purpose and nature of the questionnaire, emphasising its role in understanding emotional expressions. Prior to participation, informed consent was taken, with the estimated completion time for the questionnaire being 10–15 minutes. Confidentiality of responses was assured, and participants had the right to refuse or leave the study without giving a reason. They were encouraged to review the consent form before proceeding. In all, 110 participants were given the data collection tool. The forms received back were 104. Out of the total participants, six did not provide responses, resulting in a response rate of 94.5%. But some forms received were not complete and, therefore, were not included in this study. Hence, 100 responses of participants which were complete were used for this study.

Observations and Results

Section 1: Demographic Details of UC Patients

Table 1 shows the demographic characters of UC patients: Majority of the patients were in the age group of 40–44 years (39%), while 30–34 years was 12%, 35–39 years was 21% and 45–49 years was 28%. Males and females were equal, that is, 50%. Middle socioeconomic status was 43%, high 35% and low was 22%. Most of the patients belonged to urban areas (81%) and few (19%) belonged to rural areas. Graduates were 56%, postgraduates were 35% and undergraduates were 9%. Among these patients married were 76%, unmarried were 15% and widow/widower were 9%. Working group was 86% and not working were 14%.

Table 1.

Demographic Details of UC Patients.

Variable		Frequency	Percentage
Age	30–34 years	12	12
	35–39 years	21	21
	40–44 years	39	39
	45–49 years	28	28
Gender	Male	50	50
	Female	50	50
Socioeconomic status	Low	22	22
	Middle	43	43
	High	35	35
Place of stay	Rural	19	19
	Urban	81	81
Education	Undergraduate	9	9
	Graduate	56	56
	Postgraduate	35	35
Marital status	Married	76	76
	Unmarried	15	15
	Widow/widower	9	9
Working	Working	86	86
	Not working	14	14

Section 2: FEICS Score of the UC Patients

Table 2 shows that the mean perceived criticism (PC) score of the UC patients on FEICS is 14.87 out of 28 and mean EI score is 17.24 out of 28, and the total mean score is 32.11, which shows high EE.

Table 2.

FEICS Score of Ulcerative Colitis Patients (n = 100).

	PC	EI	Total Score
FEICS Score	Max Score 28	Max Score 28	Max Score 56
	Mean Score	Mean Score	Mean Score
	14.87	17.24	32.11

Figure 1.

FEICS Scale and Sub Scale Score Among UC Patients.

Figure 2.

Perceived Criticism Score Among the UC Patients.

Figure 3.

Emotional Involvement Score Among the UC Patients.

Table 3 shows that all 100% of the patients have moderate PC, whereas 9% had mild EI, 54% had moderate and 37% had severe EI.

Table 3.

FEICS Sub Scale Score Among UC Patients (n = 100).

PC Scale	Total Score 28	Category	Number of UC Patients
	0–9	Mild	0
	10–19	Moderate	100
	20–27	Severe	0
EI scale	Total Score 28	Category	Number of UC Patients
	0–9	Mild	9
	10–19	Moderate	54
	20–27	Severe	37

In addition to the main test examining EE levels, demographic variables were assessed within the UC group. These variables included age, gender, educational attainment, family structure, employment status, socio-economic status (SES), marital standing and geographic location of residence. Upon analysis, none of the demographic factors demonstrated a statistically significant effect on the presence of UC in this sample. This suggests that within the scope of this study, age, gender, educational attainment, family structure, employment status, SES, marital standing and geographic location of residence did not appear to be associated with the presence of UC.

Discussion

The present study delved into the examination of EE in individuals diagnosed with UC. The primary objective was to gain a comprehensive understanding of the emotional dynamics in UC patients, shedding light on potential areas of concern and support. The assessment tool employed, the FEICS-II, proved to be a valuable instrument for measuring EE. This article used FEICS to gain insights about EE from the patient’s perspective. A similar study was done in 1994 by Shields et al., where this scale was given to patients being monitored for cardiovascular disease. Notably, a larger proportion of UC patients demonstrated heightened EE, signifying a potentially distinctive emotional profile within this demographic. Previous research on various disorders consistently indicates a strong correlation between high levels of EE within families and the presence of psychological disturbances. Hibbs et al. (1991) conducted a pivotal study examining EE in families with disturbed children. Their findings showed high levels of EE in families of children with psychological disturbances as compared to those who had no psychological disturbance. This study thus highlighted the important role of family dynamics in increasing emotional expressions. ³⁰ Burkhouse, Uhrlass and Stone (2012) also demonstrated that criticism, which is a key factor of EE, predicted the outset of depression in children. ³¹ All these depict the extreme impact of family environments on the mental health of individuals, especially children.

The high levels of EE seen in patients with UC could be due to the multifaceted nature of living with a chronic condition. The challenges posed by UC in daily life, which may be the consistent physical discomfort to the lifestyle adjustments, are likely to give rise to increased emotional reactivity. Living with a chronic condition requires a continuous process of adaptation, and this can lead to a sense of unpredictability and loss of control. When people struggle with the numerous psychological and physiological effects of their illness, these elements may lead to heightened emotional expressiveness. Additionally, there is a significant emotional consequence from UC. People may become more emotionally reactive due to the ongoing management of their symptoms and possible restrictions on their everyday activities. They may feel anxious, frustrated, or like their quality of life is being compromised. This is in line with studies by Ng, Fung and Gao (2020), who showed that high EE levels may be the result of hidden abrasive behaviours in families of people with schizophrenia. ³² Similarly, the unpredictable nature and chronicity of UC can cause emotional abrasions and subtle tensions within the family, which can elevate EE even more.

UC patients’ emotional experiences are greatly influenced by their familial context, which serves as their main emotional and supportive network. Excessive emotional expression in the family setting could be a reflection of the difficulties in managing a chronic disease, which requires both the patient and their immediate caregivers to negotiate a challenging emotional terrain. Due to their significant emotional investment in their loved ones’ well-being, caregivers may exhibit elevated emotional responses when they observe the difficulties and uncertainty associated with UC. The way that emotions interact within a family may be a factor in the general atmosphere that is marked by high emotional expression. The family may also act as a sounding board for the emotional experiences of the person with UC, which could enhance the way that emotions are expressed when they are discussed and dealt with in the context of the family. In their meta-analytic review, Fahrer et al. (2022) highlighted the function of EE as a mechanism for the transmission of mental disorders across generations. ³³ This suggests that heightened emotional expressions within families may not only be a reaction to the immediate circumstances but also reflect deeper intergenerational patterns influenced by the presence of chronic illness. In the case of UC, the chronicity of the condition may exacerbate these underlying familial dynamics, leading to higher levels of EE.

Reducing EE in UC patients is crucial for their well-being. Strategies include psychoeducation for patients and families, emphasising condition management and emotional implications. Guided self-help and skill-building techniques, supported by studies, show promise in decreasing EE. Fostering coping skills, stress management and effective communication in families aids emotional regulation. Mindfulness practices tailored to UC challenges and professional counselling could also prove beneficial. These approaches create a nurturing environment, enhancing UC patients’ overall well-being.

Limitations and Future Implications

While our study sheds light on EE in UC patients, certain limitations warrant consideration. The sample size, though substantial, may benefit from further expansion to enhance generalisability. Additionally, the study focused primarily on the quantitative assessment of EE; incorporating qualitative methodologies could yield deeper insights. Future research endeavours might explore the nuanced interplay between UC symptomatology, family dynamics and emotional expression. Longitudinal studies tracking emotional trajectories over time could provide a more comprehensive understanding. Furthermore, interventions targeting EE could be a promising avenue for improving the holistic well-being of UC patients and their families, warranting exploration in future research. The implications of these findings extend beyond the confines of this study. Understanding the dynamics of EE in UC patients offers valuable insights for healthcare professionals and family members alike. Tailoring support strategies to address emotional well-being, in conjunction with medical management, may contribute to an improved quality of life for individuals affected by UC.

Conclusion

In conclusion, this study brings out the significance of assessing EE in UC patients. The heightened levels of EE observed within this population highlight the need for a holistic approach to care, encompassing both medical and psychosocial dimensions. Future research endeavours may delve further into the specific factors contributing to EE in UC patients, paving the way for more targeted interventions.