Psychosocial interventions for expressed emotion in bipolar affective disorder: A key to care

Dear Editor, Bipolar affective disorder (BPAD) is a complex severe mental disorder caused by interactions between biological, psychological, and social factors, often sensitive to changes in the environment.[1] Though pharmacotherapy is the mainstay of treatment, psychosocial interventions, especially focusing on expressed emotion (EE), helps with earlier recovery in BPAD.[2,3] This case report briefly illustrates the psychosocial model of treatment for EE and its impact on the outcome in a person with BPAD. A 24-year-old graduate, single, female, born of second-degree consanguineous marriage, with familial predisposition to affective illness and psychosis, presented with symptoms of elated mood, unprovoked irritability, increased talkativeness, unsolicited singing, wandering tendency, delusions of persecution, love, and grandiosity, along with auditory hallucinations. She presented with similar mood symptoms in the absence of psychotic symptoms in the past with irregular compliance to medication. She was diagnosed with BPAD, current episode manic with psychotic symptoms. She was started on antipsychotic medication and mood stabilizers, according to the prescribed guidelines. These symptoms were noticed to significantly affect her personal and social functioning in the form of self-care deficits and interpersonal difficulties at work and in the family. A detailed study of family interactions and dynamics revealed a male-dominated family, with the father as the head. The interaction between siblings and parents was adequate with substantial cohesiveness, problem-solving, and secondary social support. However, the course of the illness had taken significant toll over the existing family dynamics. The levels of EE in the family including perceived criticism and intensity of emotional over-involvement was assessed using Family Emotional Involvement and Criticism Scale.[4] As the EE was found to be high within the family and was found to be adversely affecting the recovery process of the patient,[5] it was decided to provide psychosocial interventions to reduce the EE in the family.[6] Family interventions were taken up in 3 sessions including psychoeducation regarding the biopsychosocial causes, course and prognosis of the illness, addressing the myths and misconceptions, identifying early signs, and symptoms of the episode, followed by family communication training in reducing negative interactions, one after the other, targeting to reduce the high EE. Subsequently, the caregivers were also engaged in 4 sessions of supportive therapy, where each family member was given the space to ventilate about their worries, with an aim to provide reassurance, clarifications, and guidance as needed. As higher relapse rates were observed when encountered with problems, the patient and caregivers were also assisted with problem-solving techniques such as identifying the problem, specifying it, choosing, implementing, and evaluating the best alternatives. As a part of vocational guidance, the patient was encouraged to seek an appropriate job and also engage in new hobbies, keeping the patient's strengths, and potentials in mind. Though the interventions had different foci and formats, they were all focused on encouraging the patient and the family to actively consort to the treatment. The EE was assessed in regular intervals and the result is presented in Table 1.Table 1: Scores of expressed emotion assessed using Family EmotionaCl Involvement and Criticism Scale in three time pointsEE is the critical, hostile, and emotionally over-involved attitude that caregivers have toward their patients with mental illness.[7,8] Psychosocial interventions, involving caregivers help reduce EE and improve understanding of illness and communication, paving way for better social functioning and treatment compliance, thereby improving the quality of life and prevent further relapse and rehospitalization. Hence, this case report reiterates the idea that psychosocial interventions targeting EE, enhances the efficacy of pharmacotherapy in promoting stabilization of illness, making it a key component in the holistic approach to BPAD. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Acknowledgments The authors are grateful to the patient and their family members.