The aim of this study was to verify the level of expressed emotion (EE) as perceived from patients with an eating disorder (ED). The Italian translation of the Level of Expressed Emotion Scale was administered to 63 female patients with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnosis of anorexia nervosa, bulimia nervosa, and binge-eating disorder and 63 control subjects, according to a case-control procedure. Patients with ED showed higher level of perceived EE than controls, whereas no significant differences were observed when comparing the 3 patient subgroups. The level of perceived EE was found to be independent of age, person who has been most influential in the patient's life, amount of contacts, and duration of treatment. Different associations between eating disorder psychopathology and EE were found, suggesting a close relationship between the emotional response and tolerance of influential person and the dysfunctional attitudes regarding eating, weight, and body shape.
The concept of expressed emotion (EE) was developed in the 1960s by Rutter and Brown [1] and [2] to assess some aspects of family life associated with relapse in patients with schizophrenia. Later, EE has been shown to be a good predictor of relapse also for patients having other psychopathologic conditions, including Alzheimer disease, anxiety disorders, depression, substance abuse, and eating disorders [3], [4], [5] and [6]. Leff and Vaughn [4] reported that high EE is characterized by 4 attitudes or response styles: (1) high level of intrusiveness (ie, making repeated attempts to establish contact or to offer unsolicited and frequently critical advice), (2) highly emotional response to the patient's illness (ie, responding with anger, acute distress, reactions that tend to upset the patient), (3) negative attitude toward the patient's illness (ie, doubting that he/she has no control over symptoms; blaming or holding the patient responsible for his/her condition), and (4) low level of tolerance and high expectations of the patient (ie, relatives are not convinced that the patient is really ill, they are intolerant of the patient's behaviors and social impairments).
As far as eating disorders (EDs) are concerned, some studies described an interaction between EE and abnormal eating behaviors, and between EE and the development and maintenance of anorexia nervosa (AN) and bulimia nervosa (BN) [5] and [7]. On the other hand, binge-eating disorder (BED) has never been explored from this point of view. The Camberwell Family Interview (CFI) [8] was the first psychometric instrument devoted to the assessment of the family emotional climate and is considered the gold standard for it. However, CFI requires time for its training, administration, and coding and also requires the availability of a key relative. The Level of Expressed Emotion (LEE) Scale [9] examines the EE perceived from the patient's perspective and has been constructed from the conceptual framework described by Vaughn and Leff [3].
The present study is aimed at the evaluation of the level of EE in families with a member having AN, BN, and BED, considering the perceived EE from the patient's perspective. In addition, we investigated the possible effect on the LEE scores of the following factors: age, duration of treatment, and amount of contact with the influential person as indicated by the patient.
